Anxiety Disorders

A new poll of emergency physicians on the front lines of the COVID-19 pandemic shows many are fearful of seeking mental health care for fear of stigma and the potential career impact.

wutwhanfoto/Getty Images

The results of the nationally representative poll, conducted Oct. 7-13 by the American College of Emergency Physicians, showed almost half (45%) of 862 emergency physician respondents reported being uncomfortable seeking available psychiatric care. The poll had a margin of error of plus or minus 3 percentage points.

The findings provide new insight into both the challenges of serving in emergency medicine during the pandemic and the persistent barriers to mental health care in terms of stigma and concerns about potential career setbacks.

In the poll, 42% of respondents said they have been feeling much more stress since the start of COVID-19, with another 45% report they were feeling somewhat more stressed.

When asked about causes of stress related directly to COVID-19, 83% cited concerns about family and friends contracting COVID-19. Also factoring into emergency physicians’ stress and burnout were concerns about their own safety (80%) and lack of personal protective equipment or other needed resources (60%).

In the poll, 29% of respondents reported having excellent access to mental health treatment and 42% reported having good access. Despite this, 30% of respondents still reported feeling there was a lot of stigma in their workplace about seeking mental health treatment, with another 43% reporting they felt there was some stigma.

Poll results also showed that 24% of respondents were very concerned about what might happen with their employment if they were to seek mental health treatment, with another 33% saying they were somewhat concerned.

In recent years there have been efforts to break down cultural roadblocks in medicine that deter many physicians from seeking mental health treatment, but more needs to be done, said Mark Rosenberg, DO, MBA, who was elected president of ACEP at last weekend’s annual meeting, ACEP20.

“The pandemic emphatically underscores our need to change the status quo when it comes to physicians’ mental health,” Dr. Rosenberg said.

As previously reported by Medscape Medical News, current efforts to remove such barriers include initiatives to limit inquiries into clinicians’ past or present mental health treatment.

In May, the influential Joint Commission issued a statement urging organizations to refrain from asking about any history of mental health conditions or treatment. The Joint Commission said it supports recommendations already made by the Federation of State Medical Boards and the American Medical Association to limit inquiries on licensing applications to conditions that currently impair a clinician’s ability to perform their job.

Also supporting these efforts is the Dr. Lorna Breen Heroes’ Foundation, created in honor of an emergency physician who died by suicide in April amid the pandemic.

Lorna Breen, MD, had been working intensely in the response to the pandemic. During one shift, she covered two EDs in Manhattan at locations 5 miles apart, according to a backgrounder on the foundation’s web site.

At an ACEP press conference this week, Dr. Breen’s brother-in-law, J. Corey Feist, JD, MBA, cofounder of the foundation, noted that some states’ licensing applications for physicians include questions that fall outside of the boundaries of the Americans With Disabilities Act. He cited an analysis of state medical boards’ initial licensing questions published in 2018 in the Journal of the American Academy of Psychiatry and the Law.

In many cases, states have posed questions that extend beyond an assessment of a physician’s current ability to care for patients, creating a needless hurdle to seeking care, wrote the paper’s lead author, Carol North, MD, of the University of Texas Southwestern Medical Center, Dallas.

“Over the years, many medical licensure boards have asked applicants intrusive questions about whether they have any psychiatric history. This has created a major problem for applicants, and unfortunately this has discouraged many of those who need psychiatric treatment from seeking it because of fear of the questions,” Dr. North and colleagues noted. They cited Ohio as an example of a state that had overhauled its approach to questioning to bring it in compliance with the ADA.

Ohio previously required applicants to answer lengthy questions about their mental health, including:

• Within the last 10 years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Have you, since attaining the age of eighteen or within the last 10 years, whichever period is shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Do you have, or have you been diagnosed as having, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?

In the new version, the single question reads: “In the past 5 years, have you been diagnosed as having, or been hospitalized for, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?”

Other states such as New York pose no mental health questions on applications for licensure.

Still, even when states have nondiscriminatory laws, physicians may not be aware of them, said Mr. Feist at an ACEP press conference. In addition to his work with the foundation, Mr. Feist is the CEO of the University of Virginia Physicians Group.

He said his sister-in-law Dr. Breen may have worried without cause about potential consequences of seeking psychiatric treatment during the pandemic. In addition, physicians in need of psychiatric care may worry about encountering hitches with medical organizations and insurers.

“This stigma and this fear of professional action on your license or your credentialing or privileging is pervasive throughout the industry,” he said.

A version of this article originally appeared on Medscape.com.

A new poll of emergency physicians on the front lines of the COVID-19 pandemic shows many are fearful of seeking mental health care for fear of stigma and the potential career impact.

wutwhanfoto/Getty Images

The results of the nationally representative poll, conducted Oct. 7-13 by the American College of Emergency Physicians, showed almost half (45%) of 862 emergency physician respondents reported being uncomfortable seeking available psychiatric care. The poll had a margin of error of plus or minus 3 percentage points.

The findings provide new insight into both the challenges of serving in emergency medicine during the pandemic and the persistent barriers to mental health care in terms of stigma and concerns about potential career setbacks.

In the poll, 42% of respondents said they have been feeling much more stress since the start of COVID-19, with another 45% report they were feeling somewhat more stressed.

When asked about causes of stress related directly to COVID-19, 83% cited concerns about family and friends contracting COVID-19. Also factoring into emergency physicians’ stress and burnout were concerns about their own safety (80%) and lack of personal protective equipment or other needed resources (60%).

In the poll, 29% of respondents reported having excellent access to mental health treatment and 42% reported having good access. Despite this, 30% of respondents still reported feeling there was a lot of stigma in their workplace about seeking mental health treatment, with another 43% reporting they felt there was some stigma.

Poll results also showed that 24% of respondents were very concerned about what might happen with their employment if they were to seek mental health treatment, with another 33% saying they were somewhat concerned.

In recent years there have been efforts to break down cultural roadblocks in medicine that deter many physicians from seeking mental health treatment, but more needs to be done, said Mark Rosenberg, DO, MBA, who was elected president of ACEP at last weekend’s annual meeting, ACEP20.

“The pandemic emphatically underscores our need to change the status quo when it comes to physicians’ mental health,” Dr. Rosenberg said.

As previously reported by Medscape Medical News, current efforts to remove such barriers include initiatives to limit inquiries into clinicians’ past or present mental health treatment.

In May, the influential Joint Commission issued a statement urging organizations to refrain from asking about any history of mental health conditions or treatment. The Joint Commission said it supports recommendations already made by the Federation of State Medical Boards and the American Medical Association to limit inquiries on licensing applications to conditions that currently impair a clinician’s ability to perform their job.

Also supporting these efforts is the Dr. Lorna Breen Heroes’ Foundation, created in honor of an emergency physician who died by suicide in April amid the pandemic.

Lorna Breen, MD, had been working intensely in the response to the pandemic. During one shift, she covered two EDs in Manhattan at locations 5 miles apart, according to a backgrounder on the foundation’s web site.

At an ACEP press conference this week, Dr. Breen’s brother-in-law, J. Corey Feist, JD, MBA, cofounder of the foundation, noted that some states’ licensing applications for physicians include questions that fall outside of the boundaries of the Americans With Disabilities Act. He cited an analysis of state medical boards’ initial licensing questions published in 2018 in the Journal of the American Academy of Psychiatry and the Law.

In many cases, states have posed questions that extend beyond an assessment of a physician’s current ability to care for patients, creating a needless hurdle to seeking care, wrote the paper’s lead author, Carol North, MD, of the University of Texas Southwestern Medical Center, Dallas.

“Over the years, many medical licensure boards have asked applicants intrusive questions about whether they have any psychiatric history. This has created a major problem for applicants, and unfortunately this has discouraged many of those who need psychiatric treatment from seeking it because of fear of the questions,” Dr. North and colleagues noted. They cited Ohio as an example of a state that had overhauled its approach to questioning to bring it in compliance with the ADA.

Ohio previously required applicants to answer lengthy questions about their mental health, including:

• Within the last 10 years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Have you, since attaining the age of eighteen or within the last 10 years, whichever period is shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Do you have, or have you been diagnosed as having, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?

In the new version, the single question reads: “In the past 5 years, have you been diagnosed as having, or been hospitalized for, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?”

Other states such as New York pose no mental health questions on applications for licensure.

Still, even when states have nondiscriminatory laws, physicians may not be aware of them, said Mr. Feist at an ACEP press conference. In addition to his work with the foundation, Mr. Feist is the CEO of the University of Virginia Physicians Group.

He said his sister-in-law Dr. Breen may have worried without cause about potential consequences of seeking psychiatric treatment during the pandemic. In addition, physicians in need of psychiatric care may worry about encountering hitches with medical organizations and insurers.

“This stigma and this fear of professional action on your license or your credentialing or privileging is pervasive throughout the industry,” he said.

A version of this article originally appeared on Medscape.com.

A new poll of emergency physicians on the front lines of the COVID-19 pandemic shows many are fearful of seeking mental health care for fear of stigma and the potential career impact.

wutwhanfoto/Getty Images

The results of the nationally representative poll, conducted Oct. 7-13 by the American College of Emergency Physicians, showed almost half (45%) of 862 emergency physician respondents reported being uncomfortable seeking available psychiatric care. The poll had a margin of error of plus or minus 3 percentage points.

The findings provide new insight into both the challenges of serving in emergency medicine during the pandemic and the persistent barriers to mental health care in terms of stigma and concerns about potential career setbacks.

In the poll, 42% of respondents said they have been feeling much more stress since the start of COVID-19, with another 45% report they were feeling somewhat more stressed.

When asked about causes of stress related directly to COVID-19, 83% cited concerns about family and friends contracting COVID-19. Also factoring into emergency physicians’ stress and burnout were concerns about their own safety (80%) and lack of personal protective equipment or other needed resources (60%).

In the poll, 29% of respondents reported having excellent access to mental health treatment and 42% reported having good access. Despite this, 30% of respondents still reported feeling there was a lot of stigma in their workplace about seeking mental health treatment, with another 43% reporting they felt there was some stigma.

Poll results also showed that 24% of respondents were very concerned about what might happen with their employment if they were to seek mental health treatment, with another 33% saying they were somewhat concerned.

In recent years there have been efforts to break down cultural roadblocks in medicine that deter many physicians from seeking mental health treatment, but more needs to be done, said Mark Rosenberg, DO, MBA, who was elected president of ACEP at last weekend’s annual meeting, ACEP20.

“The pandemic emphatically underscores our need to change the status quo when it comes to physicians’ mental health,” Dr. Rosenberg said.

As previously reported by Medscape Medical News, current efforts to remove such barriers include initiatives to limit inquiries into clinicians’ past or present mental health treatment.

In May, the influential Joint Commission issued a statement urging organizations to refrain from asking about any history of mental health conditions or treatment. The Joint Commission said it supports recommendations already made by the Federation of State Medical Boards and the American Medical Association to limit inquiries on licensing applications to conditions that currently impair a clinician’s ability to perform their job.

Also supporting these efforts is the Dr. Lorna Breen Heroes’ Foundation, created in honor of an emergency physician who died by suicide in April amid the pandemic.

Lorna Breen, MD, had been working intensely in the response to the pandemic. During one shift, she covered two EDs in Manhattan at locations 5 miles apart, according to a backgrounder on the foundation’s web site.

At an ACEP press conference this week, Dr. Breen’s brother-in-law, J. Corey Feist, JD, MBA, cofounder of the foundation, noted that some states’ licensing applications for physicians include questions that fall outside of the boundaries of the Americans With Disabilities Act. He cited an analysis of state medical boards’ initial licensing questions published in 2018 in the Journal of the American Academy of Psychiatry and the Law.

In many cases, states have posed questions that extend beyond an assessment of a physician’s current ability to care for patients, creating a needless hurdle to seeking care, wrote the paper’s lead author, Carol North, MD, of the University of Texas Southwestern Medical Center, Dallas.

“Over the years, many medical licensure boards have asked applicants intrusive questions about whether they have any psychiatric history. This has created a major problem for applicants, and unfortunately this has discouraged many of those who need psychiatric treatment from seeking it because of fear of the questions,” Dr. North and colleagues noted. They cited Ohio as an example of a state that had overhauled its approach to questioning to bring it in compliance with the ADA.

Ohio previously required applicants to answer lengthy questions about their mental health, including:

• Within the last 10 years, have you been diagnosed with or have you been treated for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Have you, since attaining the age of eighteen or within the last 10 years, whichever period is shorter, been admitted to a hospital or other facility for the treatment of bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder?
• Do you have, or have you been diagnosed as having, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?

In the new version, the single question reads: “In the past 5 years, have you been diagnosed as having, or been hospitalized for, a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety?”

Other states such as New York pose no mental health questions on applications for licensure.

Still, even when states have nondiscriminatory laws, physicians may not be aware of them, said Mr. Feist at an ACEP press conference. In addition to his work with the foundation, Mr. Feist is the CEO of the University of Virginia Physicians Group.

He said his sister-in-law Dr. Breen may have worried without cause about potential consequences of seeking psychiatric treatment during the pandemic. In addition, physicians in need of psychiatric care may worry about encountering hitches with medical organizations and insurers.

“This stigma and this fear of professional action on your license or your credentialing or privileging is pervasive throughout the industry,” he said.

A version of this article originally appeared on Medscape.com.

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Last summer, back when people traveled, I had the pleasure of being in Amsterdam for Pride Week. With a half-million tourists, it was a colorful and costumed display of LGBTQ pride, and both the streets and canals had celebrations with food, drinks, music, and displays beyond anything I could describe.

It was all not that long ago that the American Psychiatric Association classified homosexuality as a psychiatric disorder. Now we have Pride celebrations, and I don’t think twice about mentioning my brother-in-law’s husband, or a female colleague’s wife, nor am I shocked when I hear that the children of my friends are in the process of gender transition. Obviously, the idea that people express both their gender and their sexuality in diverse ways is not accepted by everyone, but we’ve come a long way toward acceptance of people who were once stigmatized and pathologized. I’ll also point out that this shift occurred despite the fact that the gay community was affected by AIDS.

There are many other differences – and illnesses – that our society has come to either accept or sympathize with more graciously over time, and yet both mental illness and substance abuse disorders remain stigmatized and punished. To put it bluntly, we have done a terrible job of making these conditions acceptable illnesses to have, even though we have done a reasonably good job of offering effective treatments. Cancer no longer carries the stigma it once did, even though cancer is a leading cause of death, and the treatments are painful, toxic, and may include the loss of body parts and hair. But if you become ill with cancer, your friends bring casseroles (or perhaps rotisserie chickens), and if you’re hospitalized with bipolar disorder or check into a drug treatment center, you’re more likely to be the recipient of judgment and even scorn.

We have to fix this. We talk about the need to destigmatize mental illness and substance use disorders, and to make these illnesses more on par with other diseases. Maybe that is the wrong call: These disorders sometimes cause people to behave in disruptive, dangerous, and illegal ways that we don’t often see with other illnesses. Frankly psychotic people may be seen as “other,” they may smell bad, they may behave in bizarre ways, and they may be frightening. Their rare acts of violence have been publicized so much that “He’s mentally ill” is accepted by the public as a full explanation for why someone would commit a mass shooting. Depression can cause people to be irritable and unpleasant, and our society equates a lack of motivation with laziness. While people may have sympathy for the suicidal thoughts and feelings of others, completed suicide leaves behind devastated survivors. People with substance use problems may become belligerent or commit crimes to support their addictions. In 2018, over 10,500 people were killed by drivers who were impaired by alcohol. I’m not sure how we destigmatize these conditions, but commercials, billboards, and educational programs aren’t doing it.
 

Fears around treatment

Perhaps our efforts need to go toward destigmatizing treatment. It is shocking to me how resistant people are to getting help, or having others know they are getting help, when treatment often renders them free from the psychological agony or misbehaviors caused by their condition.

Since I work in an outpatient setting, I see people who have made it beyond the barrier of seeking help. Almost all of my patients are willing to try medications – there is self-selection among those who chose to see a psychiatrist as opposed to another type of psychotherapist. I also believe that direct-to-consumer advertising has helped normalize the use of psychotropic medications.

When it comes to getting a higher level of care, however, the conversations are so much harder. Many of my patients insist they will never be admitted to a psychiatric unit, and when I ask depressed people if they are having suicidal thoughts, some tell me they are afraid to let me know they are for fear I might hospitalize them. This fear of hospitalization is present in people who have never been in a hospital and have only media depictions or their imaginations to go by, but I also see this with patients who have previously been hospitalized and have emerged from their inpatient stays feeling much better. While we know that any type of hospitalization involves a loss of control, unpleasant moments, and sometimes painful procedures, I have never heard anyone say that, if they were to have a second heart attack, they would refuse an admission to the cardiac care unit.

Discussions about treatment for substance use are even more difficult. People with addictions often don’t want to abstain from the substance they are using, and this is an enormous hurdle. Beyond that, they don’t like the labels that come with acknowledging a problem – words like “junkie,” “addict,” “drunk,” and “alcoholic” are hard to escape.

People fear hospitalization for many reasons: They fear losing control, they don’t recognize that they have a problem, or they rationalize their psychosis or substance use as normal. Most of all, they fear what others will think of them and what repercussions this will have for their futures. Patients would rather continue in a state of agony and dysfunction when inpatient treatment would make them better faster. This is nothing short of tragic.

What can we do? The answer is “a lot.” We need to work harder to make the hospital experience a pleasant one for patients. Inpatient units need to be clean, safe places where patients are treated with kindness, dignity, and respect and activities are appropriate, interesting, and promote healing.

Maria, a Maryland attorney, told me about her experience with inpatient treatment. “I experienced my hospitalization as jailing and acutely felt the loss of liberty, especially in the ER, where I was confined to something I recognized from my time visiting incarcerated and detained people as a holding cell, complete with a uniformed guard. I was scared to engage in any kind of meaningful self-advocacy around leaving out of fear for my license to practice law and of lengthening my time as an inpatient. As a result, I found myself concentrating on getting out, and not on getting well. With the benefit of hindsight, I can say now that my hospitalization was a lost opportunity, and the coercive elements were barriers to accessing the treatment that I needed, both at the time and in the years following the hospitalization.”

We have too many policies in place where infractions are met with force, seclusion, and sometimes restraint, and we need to be more flexible with these policies. If a psychiatric unit requires lab work prior to admission and the patient refuses, should force be used in the emergency department if there is nothing to indicate that the patient’s health is in imminent danger? And if the hospital has a policy that all psychiatric patients must disrobe to be examined for preexisting scars or contraband – this is an admission standard for some hospitals, but not others – and the patient refuses, what then? Typically, inpatients are not allowed access to their cell phones or the Internet (for many good reasons), but patients find this very upsetting; might it make sense to allow periods where they can use devices with supervision? Hospitals often forbid smoking, and people with psychiatric disorders may smoke – while it is a wonderful health ideal, is it reasonable to forbid smoking for the course of a hospitalization? Rigid adherence to policies does not always serve our patients well, and it sometimes creates dangerous situations for everyone.

We must work to get questions about psychiatric and substance use disorders removed from any job- or licensure-related forms. There is no reason to believe that people answer these forms truthfully or that including these questions protects the public in any way. What we do know is that people don’t seek help because they, like Maria, are afraid of the consequences of getting care. It doesn’t matter if a surgeon’s abilities are limited because he has episodes of hypoglycemia or past episodes of mania, and the only question on licensing forms should be about current conditions that impair the ability to work. Every district branch of the American Psychiatric Association should be actively speaking with their state professional licensing boards about the harm these questions do.

We need better treatments that have fewer side effects, and we need to acknowledge that, while getting help is the right thing to do, not everyone finds the right treatment with the first attempt and not everyone gets better. Our party line to those who feel suicidal has been “Get Help,” often with a phone number for the National Suicide Prevention Lifeline. While this is an important resource to have readily available, many of the people who die of suicide are already in active treatment. Our party line needs to change to “Get Help, and if it isn’t working, Get Different Help.” We want to be careful that our messaging does not foster a sense of hopelessness in those who have sought care and still suffer.

It’s good to talk about the potential benefits of treatment, but we don’t have enough beds and we don’t have enough mental health clinicians. There are states where psychiatric patients who have committed no crime are held in jail cells while they wait for beds to open – that we allow this is nothing short of a disgrace. The sickest patients with treatment-resistant conditions need access to the best care, and that access should not be limited by finances or networks. And while I’m here: We need our mental health professionals to spend their time working with patients, not computer screens, check boxes, and prior authorization protocols.

Finally, we need to work with the media to show positive and accurate depictions of psychiatric treatment as something that helps. We are still undoing the harm of Nurse Ratched and the depiction of electroconvulsive therapy in the 1975 film “One Flew Over the Cuckoo’s Nest,” and the current focus on mental illness and violence does nothing to help people feel comfortable seeking care.

I’ll end with one more thought from Maria: “Mental health professionals need to talk about hospitalization up front, no matter how uncomfortable, and encourage patients to think about hospitalization as a treatment option on a continuum before it is needed, so they are not approaching hospitalization as an abstract concept, often with a lot of fear and stigma attached to it, but rather as an option that they might explore in a fact-based way.”
 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. She reported having nothing to disclose.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

[email protected]

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

[email protected]

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

Adjunctive pimavanserin brought clinically meaningful improvement in patients with anxious major depressive disorder inadequately responsive to standard antidepressants alone in a post hoc analysis of the CLARITY trial, Bryan Dirks, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.

This is an intriguing observation, because it’s estimated that roughly 50% of individuals with major depressive disorder (MDD) have comorbid anxiety disorders or a high level of anxiety symptoms. Moreover, anxious depression has been associated with increased risk of suicidality, high unemployment, and impaired functioning.

CLARITY was a phase 2, multicenter, randomized, double-blind, placebo-controlled clinical trial whose positive results for the primary outcome have been published (J Clin Psychiatry. 2019 Sep 24;80[6]:19m12928. doi: 10.4088/JCP.19m12928). Because the encouraging findings regarding pimavanserin’s impact on anxious depression came from a post hoc analysis, the results need replication. That’s ongoing in a phase 3 trial of adjunctive pimavanserin versus placebo in patients with MDD, according to Dr. Dirks, director of clinical research at Acadia Pharmaceuticals, San Diego.

The CLARITY post hoc analysis included 104 patients with baseline MDD inadequately responsive to an SSRI or a serotonin norepinephrine reuptake inhibitor and anxious depression as defined by a Hamilton Depression Rating Scale (HAMD-17) anxiety/somatization factor subscale score of 7 or more. Twenty-nine of the patients were randomized to 34 mg of adjunctive oral pimavanserin once daily, and 75 to placebo. At 5 weeks, the HAMD-17 anxiety/somatization factor score in the pimavanserin group had dropped by a mean of 5 points from a baseline of 8.8, a significantly greater effect than the 2.8-point drop in placebo-treated controls.

By week 5, the treatment response rate as defined by at least a 50% reduction in HAMD-17 total score from baseline was 55% with pimavanserin and 22% with placebo. The remission rate as indicated by a HAMD-17 total score below 7 was 24% in the pimavanserin group, compared with 5% with placebo. These results translated into an effect size of 0.78, considered by statisticians to be on the border between medium and large. Those response and remission rates in patients with anxious depression were higher with pimavanserin and lower with placebo than in the overall CLARITY trial.

The impact of adjunctive pimavanserin on top of a background SSRI or SNRI was even more pronounced in the subgroup of patients with baseline severe MDD as defined by a HAMD-17 total score of 24 or more plus an anxiety/somatization factor score of 7 or greater. Seventeen such patients were randomized to adjunctive pimavanserin, 36 to placebo. At 5 weeks, the mean HAMD total score had dropped by 17.4 points from a baseline of 27.6 in the pimavanserin group, compared with a 9.3-point reduction in controls.

“Of note, significant differences from placebo were observed as early as week 2 with pimavanserin,” Dr. Dirks said.

Pimavanserin is a novel selective serotonin inverse agonist with a high affinity for 5-HT2A receptors and low affinity for 5-HT2C receptors. At present pimavanserin is Food Drug Administration–approved as Nuplazid only for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis, but because of the drug’s unique mechanism of action it is under study for a variety of other mental disorders. Indeed, pimavanserin is now under FDA review for a possible expanded indication for treatment of dementia-related psychosis. The drug is also under study for schizophrenia as well as for MDD.

The CLARITY trial and this post hoc analysis were sponsored by Acadia Pharmaceuticals.

[email protected]

SOURCE: Dirks B. ECNP 2020. Abstract P 094.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

The mental health consequences of COVID-19 deaths are likely to overwhelm an already tattered U.S. mental health system, leading to a lack of access, particularly for the most vulnerable, experts warn.

“A second wave of devastation is imminent, attributable to mental health consequences of COVID-19,” write Naomi Simon, MD, and coauthors with the department of psychiatry, New York University.

In a Viewpoint article published in JAMA on Oct. 12, physicians offer some sobering statistics.

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

The psychological risks for health care and other essential workers are of particular concern, they say. “Supporting the mental health of these and other essential workforce is critical to readiness for managing recurrent waves of the pandemic,” they stated.

How will the United States manage this impending wave of mental health problems?

“The solution will require increased funding for mental health; widespread screening to identify individuals at highest risk including suicide risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations,” the authors wrote.

“History has shown that societies recover from such devastation when leaders and members are joined by a shared purpose, acting in a unified way to facilitate recovery. In such societies, there is a shared understanding that its members must care for one another because the loss of one is a loss for all. Above all, this shared understanding must be restored,” they concluded.

Dr. Simon has received personal fees from Vanda Pharmaceuticals Inc, MGH Psychiatry Academy, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, and Wiley (deputy editor, Depression and Anxiety). Saxe has received royalties from Guilford Press for the book Trauma Systems Therapy for Children and Teens (2016). Marmar serves on the scientific advisory board and owns equity in Receptor Life Sciences and serves on the PTSD advisory board for Otsuka Pharmaceutical.
 

A version of this article originally appeared on Medscape.com.

New research shows that about a quarter of police officers in one large force report past or present mental health problems.

Responding to a survey, 26% of police officers on the Dallas police department screened positive for depression, anxiety, PTSD, or symptoms of suicide ideation or self-harm.

Mental illness rates were particularly high among female officers, those who were divorced, widowed, or separated, and those with military experience.

The study also showed that concerns over confidentiality and stigma may prevent officers with mental illness from seeking treatment.

The results underscored the need to identify police officers with psychiatric problems and to connect them to the most appropriate individualized care, author Katelyn K. Jetelina, PhD, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.

“This is a very hard-to-reach population, and because of that, we need to be innovative in reaching them for services,” she said.

The study was published online Oct. 7 in JAMA Network Open.

Dr. Jetelina and colleagues are investigating various aspects of police officers’ well-being, including their nutritional needs and their occupational, physical, and mental health.

The current study included 434 members of the Dallas police department, the ninth largest in the United States. The mean age of the participants was 37 years, 82% were men, and about half were White. The 434 officers represented 97% of those invited to participate (n = 446) and 31% of the total patrol population of the Dallas police department (n = 1,413).

These officers completed a short survey on their smartphone that asked about lifetime diagnoses of depression, anxiety, and PTSD. They were also asked whether they experienced suicidal ideation or self-harm during the previous 2 weeks.

Overall, 12% of survey respondents reported having been diagnosed with a mental illness. This, said Jetelina, is slightly lower than the rate reported in the general population.

Study participants who had not currently been diagnosed with a mental illness completed the Patient Health Questionnaire–2 (PHQ-2), the Generalized Anxiety Disorder–2 (GAD-2), and the Primary Care–Posttraumatic Stress Disorder (PC-PTSD).

Officers were considered to have a positive result if they had a score of 3 or more (PHQ-2, sensitivity of 83% and specificity of 92%; PC-PTSD-5, sensitivity of 93% and specificity of 85%; GAD-2, sensitivity of 86% and specificity of 83%).

About 26% of respondents had a positive screening for mental illness symptoms, mainly PTSD and depression, which Dr. Jetelina noted is a higher percentage than in the general population.

This rate of mental health symptoms is “high and concerning,” but not surprising because of the work of police officers, which could include attending to sometimes violent car crashes, domestic abuse situations, and armed conflicts, said Dr. Jetelina.

“They’re constantly exposed to traumatic calls for service; they see people on their worst day, 8 hours a day, 5 days a week. That stress and exposure will have a detrimental effect on mental health, and we have to pay more attention to that,” she said.

Dr. Jetelina pointed out that the surveys were completed in January and February 2020, before COVID-19 had become a cause of stress for everyone and before the increase in calls for defunding police amid a resurgence of Black Lives Matter demonstrations.

However, she stressed that racial biases and occupational stress among police officers are “nothing new for them.” For example, in 2016, five Dallas police officers were killed during Black Lives Matter protests because of their race/ethnicity.
 

More at risk

The study showed that certain subgroups of officers were more at risk for mental illness. After adjustment for confounders, including demographic characteristics, marital status, and educational level, the odds of being diagnosed with a mental illness during the course of one’s life were significantly higher among female officers than male officers (adjusted odds ratio, 3.20; 95% confidence interval, 1.18-8.68).

Officers who were divorced, widowed, or separated and those who had more experience and held a higher rank were also at greater risk for mental illness.

As well, military veterans had greater odds of being diagnosed with a mental health disorder, compared with nonveterans (aOR, 3.25; 95% CI, 1.38-7.67).

The study also asked participants about use of mental health care services over the past 12 months. About 35% of those who had a current mental health diagnosis and 17% of those who screened positive for mental health symptoms reported using such services.

The study also asked those who screened positive about their interest in seeking such services. After adjustments, officers with suicidal ideation or self-harm were significantly more likely to be interested in getting help, compared with officers who did not report suicidal ideation or self-harm (aOR, 7.66; 95% CI, 1.70-34.48).

Dr. Jetelina was impressed that so many officers were keen to seek help, which “is a big positive,” she said. “It’s just a matter of better detecting who needs the help and better connecting them to medical services that meet their needs.”
 

Mindfulness exercise

Dr. Jetelina and colleagues are conducting a pilot test of the use by police officers of smartwatches that monitor heart rate and oxygen levels. If measurements with these devices reach a predetermined threshold, the officers are “pinged” and are instructed to perform a mindfulness exercise in the field, she said.

Results so far “are really exciting,” said Dr. Jetelina. “Officers have found this extremely helpful and feasible, and so the next step is to test if this truly impacts mental illness over time.”

Routine mental health screening of officers might be beneficial, but only if it’s conducted in a manner “respectful of the officers’ needs and wants,” said Dr. Jetelina.

She pointed out that although psychological assessments are routinely carried out following an extreme traumatic call, such as one involving an officer-involved shooting, the “in-between” calls could have a more severe cumulative impact on mental health.

It’s important to provide officers with easy-to-access services tailored for their individual needs, said Dr. Jetelina.
 

‘Numb to it’

Eighteen patrol officers also participated in a focus group, during which several themes regarding the use of mental health care services emerged. One theme was the inability of officers to identify when they’re personally experiencing a mental health problem.

Participants said they had become “numb” to the traumatic events on the job, which is “concerning,” Dr. Jetelina said. “They think that having nightmares every week is completely normal, but it’s not, and this needs to be addressed.”

Other themes that emerged from focus groups included the belief that psychologists can’t relate to police stressors; concerns about confidentiality (one sentiment that was expressed was “you’re an idiot” if you “trust this department”); and stigma for officers who seek mental health care (participants talked about “reprisal” from seeing “a shrink,” including being labeled as “a nutter” and losing their job).

Dr. Jetelina noted that some “champion” officers revealed their mental health journey during focus groups, which tended to “open a Pandora’s box” for others to discuss their experience. She said these champions could be leveraged throughout the police department to help reduce stigma.

The study included participants from only one police department, although rigorous data collection allows for generalizability to the entire patrol department, say the authors. Although the study included only brief screens of mental illness symptoms, these short versions of screening tests have high sensitivity and specificity for mental illness in primary care, they noted.

The next step for the researchers is to study how mental illness and symptoms affect job performance, said Dr. Jetelina. “Does this impact excessive use of force? Does this impact workers’ compensation? Does this impact dispatch times, the time it takes for a police officer to respond to [a] 911 call?”
 

Possible underrepresentation

Anthony T. Ng, MD, regional medical director, East Region Hartford HealthCare Behavioral Health Network in Mansfield, Conn., and member of the American Psychiatric Association’s Council on Communications, found the study “helpful.”

However, the 26% who tested positive for mental illness may be an “underrepresentation” of the true picture, inasmuch as police officers might minimize or be less than truthful about their mental health status, said Dr. Ng.

Law enforcement has “never been easy,” but stressors may have escalated recently as police forces deal with shortages of staff and jails, said Dr. Ng.

He also noted that officers might face stressors at home. “Evidence shows that domestic violence is quite high – or higher than average – among law enforcement,” he said. “All these things add up.”

Psychiatrists and other mental health professionals should be “aware of the unique challenges” that police officers face and be “proactively involved” in providing guidance and education on mitigating stress, said Dr. Ng.

“You have police officers wearing body armor, so why can’t you give them some training to learn how to have psychiatric or psychological body armor?” he said. But it’s a two-way street; police forces should be open to outreach from mental health professionals. “We have to meet halfway.”
 

Compassion fatigue

In an accompanying commentary, John M. Violanti, PhD, of the department of epidemiology and environmental health at the State University of New York at Buffalo, said the article helps bring “to the forefront” the issue of the psychological dangers of police work.

There is conjecture as to why police experience mental distress, said Dr. Violanti, who pointed to a study of New York City police suicides during the 1930s that suggested that police have a “social license” for aggressive behavior but are restrained as part of public trust, placing them in a position of “psychological strain.”

“This situation may be reflective of the same situation police find themselves today,” said Dr. Violanti.

“Compassion fatigue,” a feeling of mental exhaustion caused by the inability to care for all persons in trouble, may also be a factor, as could the constant stress that leaves police officers feeling “cynical and isolated from others,” he wrote.

“The socialization process of becoming a police officer is associated with constrictive reasoning, viewing the world as either right or wrong, which leaves no middle ground for alternatives to deal with mental distress,” Dr. Violanti said.

He noted that police officers may abuse alcohol because of stress, peer pressure, isolation, and a culture that approves of alcohol use. “Officers tend to drink together and reinforce their own values.”.

Although no prospective studies have linked police mental health problems with childhood abuse or neglect, some mental health professionals estimate that about 25% of their police clients have a history of childhood abuse or neglect, said Dr. Violanti.

He agreed that mindfulness may help manage stress and increase cognitive flexibility in dealing with trauma and crises.

A possible way to ensure confidentiality is a peer support program that allows distressed officers to first talk privately with a trained and trusted peer officer and to then seek professional help if necessary, said Dr. Violanti.

The study was funded by a grant from the National Institute of Occupational Health and Safety. Dr. Jetelina, Dr. Ng, and Dr. Violanti disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

New research shows that about a quarter of police officers in one large force report past or present mental health problems.

Responding to a survey, 26% of police officers on the Dallas police department screened positive for depression, anxiety, PTSD, or symptoms of suicide ideation or self-harm.

Mental illness rates were particularly high among female officers, those who were divorced, widowed, or separated, and those with military experience.

The study also showed that concerns over confidentiality and stigma may prevent officers with mental illness from seeking treatment.

The results underscored the need to identify police officers with psychiatric problems and to connect them to the most appropriate individualized care, author Katelyn K. Jetelina, PhD, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.

“This is a very hard-to-reach population, and because of that, we need to be innovative in reaching them for services,” she said.

The study was published online Oct. 7 in JAMA Network Open.

Dr. Jetelina and colleagues are investigating various aspects of police officers’ well-being, including their nutritional needs and their occupational, physical, and mental health.

The current study included 434 members of the Dallas police department, the ninth largest in the United States. The mean age of the participants was 37 years, 82% were men, and about half were White. The 434 officers represented 97% of those invited to participate (n = 446) and 31% of the total patrol population of the Dallas police department (n = 1,413).

These officers completed a short survey on their smartphone that asked about lifetime diagnoses of depression, anxiety, and PTSD. They were also asked whether they experienced suicidal ideation or self-harm during the previous 2 weeks.

Overall, 12% of survey respondents reported having been diagnosed with a mental illness. This, said Jetelina, is slightly lower than the rate reported in the general population.

Study participants who had not currently been diagnosed with a mental illness completed the Patient Health Questionnaire–2 (PHQ-2), the Generalized Anxiety Disorder–2 (GAD-2), and the Primary Care–Posttraumatic Stress Disorder (PC-PTSD).

Officers were considered to have a positive result if they had a score of 3 or more (PHQ-2, sensitivity of 83% and specificity of 92%; PC-PTSD-5, sensitivity of 93% and specificity of 85%; GAD-2, sensitivity of 86% and specificity of 83%).

About 26% of respondents had a positive screening for mental illness symptoms, mainly PTSD and depression, which Dr. Jetelina noted is a higher percentage than in the general population.

This rate of mental health symptoms is “high and concerning,” but not surprising because of the work of police officers, which could include attending to sometimes violent car crashes, domestic abuse situations, and armed conflicts, said Dr. Jetelina.

“They’re constantly exposed to traumatic calls for service; they see people on their worst day, 8 hours a day, 5 days a week. That stress and exposure will have a detrimental effect on mental health, and we have to pay more attention to that,” she said.

Dr. Jetelina pointed out that the surveys were completed in January and February 2020, before COVID-19 had become a cause of stress for everyone and before the increase in calls for defunding police amid a resurgence of Black Lives Matter demonstrations.

However, she stressed that racial biases and occupational stress among police officers are “nothing new for them.” For example, in 2016, five Dallas police officers were killed during Black Lives Matter protests because of their race/ethnicity.
 

More at risk

The study showed that certain subgroups of officers were more at risk for mental illness. After adjustment for confounders, including demographic characteristics, marital status, and educational level, the odds of being diagnosed with a mental illness during the course of one’s life were significantly higher among female officers than male officers (adjusted odds ratio, 3.20; 95% confidence interval, 1.18-8.68).

Officers who were divorced, widowed, or separated and those who had more experience and held a higher rank were also at greater risk for mental illness.

As well, military veterans had greater odds of being diagnosed with a mental health disorder, compared with nonveterans (aOR, 3.25; 95% CI, 1.38-7.67).

The study also asked participants about use of mental health care services over the past 12 months. About 35% of those who had a current mental health diagnosis and 17% of those who screened positive for mental health symptoms reported using such services.

The study also asked those who screened positive about their interest in seeking such services. After adjustments, officers with suicidal ideation or self-harm were significantly more likely to be interested in getting help, compared with officers who did not report suicidal ideation or self-harm (aOR, 7.66; 95% CI, 1.70-34.48).

Dr. Jetelina was impressed that so many officers were keen to seek help, which “is a big positive,” she said. “It’s just a matter of better detecting who needs the help and better connecting them to medical services that meet their needs.”
 

Mindfulness exercise

Dr. Jetelina and colleagues are conducting a pilot test of the use by police officers of smartwatches that monitor heart rate and oxygen levels. If measurements with these devices reach a predetermined threshold, the officers are “pinged” and are instructed to perform a mindfulness exercise in the field, she said.

Results so far “are really exciting,” said Dr. Jetelina. “Officers have found this extremely helpful and feasible, and so the next step is to test if this truly impacts mental illness over time.”

Routine mental health screening of officers might be beneficial, but only if it’s conducted in a manner “respectful of the officers’ needs and wants,” said Dr. Jetelina.

She pointed out that although psychological assessments are routinely carried out following an extreme traumatic call, such as one involving an officer-involved shooting, the “in-between” calls could have a more severe cumulative impact on mental health.

It’s important to provide officers with easy-to-access services tailored for their individual needs, said Dr. Jetelina.
 

‘Numb to it’

Eighteen patrol officers also participated in a focus group, during which several themes regarding the use of mental health care services emerged. One theme was the inability of officers to identify when they’re personally experiencing a mental health problem.

Participants said they had become “numb” to the traumatic events on the job, which is “concerning,” Dr. Jetelina said. “They think that having nightmares every week is completely normal, but it’s not, and this needs to be addressed.”

Other themes that emerged from focus groups included the belief that psychologists can’t relate to police stressors; concerns about confidentiality (one sentiment that was expressed was “you’re an idiot” if you “trust this department”); and stigma for officers who seek mental health care (participants talked about “reprisal” from seeing “a shrink,” including being labeled as “a nutter” and losing their job).

Dr. Jetelina noted that some “champion” officers revealed their mental health journey during focus groups, which tended to “open a Pandora’s box” for others to discuss their experience. She said these champions could be leveraged throughout the police department to help reduce stigma.

The study included participants from only one police department, although rigorous data collection allows for generalizability to the entire patrol department, say the authors. Although the study included only brief screens of mental illness symptoms, these short versions of screening tests have high sensitivity and specificity for mental illness in primary care, they noted.

The next step for the researchers is to study how mental illness and symptoms affect job performance, said Dr. Jetelina. “Does this impact excessive use of force? Does this impact workers’ compensation? Does this impact dispatch times, the time it takes for a police officer to respond to [a] 911 call?”
 

Possible underrepresentation

Anthony T. Ng, MD, regional medical director, East Region Hartford HealthCare Behavioral Health Network in Mansfield, Conn., and member of the American Psychiatric Association’s Council on Communications, found the study “helpful.”

However, the 26% who tested positive for mental illness may be an “underrepresentation” of the true picture, inasmuch as police officers might minimize or be less than truthful about their mental health status, said Dr. Ng.

Law enforcement has “never been easy,” but stressors may have escalated recently as police forces deal with shortages of staff and jails, said Dr. Ng.

He also noted that officers might face stressors at home. “Evidence shows that domestic violence is quite high – or higher than average – among law enforcement,” he said. “All these things add up.”

Psychiatrists and other mental health professionals should be “aware of the unique challenges” that police officers face and be “proactively involved” in providing guidance and education on mitigating stress, said Dr. Ng.

“You have police officers wearing body armor, so why can’t you give them some training to learn how to have psychiatric or psychological body armor?” he said. But it’s a two-way street; police forces should be open to outreach from mental health professionals. “We have to meet halfway.”
 

Compassion fatigue

In an accompanying commentary, John M. Violanti, PhD, of the department of epidemiology and environmental health at the State University of New York at Buffalo, said the article helps bring “to the forefront” the issue of the psychological dangers of police work.

There is conjecture as to why police experience mental distress, said Dr. Violanti, who pointed to a study of New York City police suicides during the 1930s that suggested that police have a “social license” for aggressive behavior but are restrained as part of public trust, placing them in a position of “psychological strain.”

“This situation may be reflective of the same situation police find themselves today,” said Dr. Violanti.

“Compassion fatigue,” a feeling of mental exhaustion caused by the inability to care for all persons in trouble, may also be a factor, as could the constant stress that leaves police officers feeling “cynical and isolated from others,” he wrote.

“The socialization process of becoming a police officer is associated with constrictive reasoning, viewing the world as either right or wrong, which leaves no middle ground for alternatives to deal with mental distress,” Dr. Violanti said.

He noted that police officers may abuse alcohol because of stress, peer pressure, isolation, and a culture that approves of alcohol use. “Officers tend to drink together and reinforce their own values.”.

Although no prospective studies have linked police mental health problems with childhood abuse or neglect, some mental health professionals estimate that about 25% of their police clients have a history of childhood abuse or neglect, said Dr. Violanti.

He agreed that mindfulness may help manage stress and increase cognitive flexibility in dealing with trauma and crises.

A possible way to ensure confidentiality is a peer support program that allows distressed officers to first talk privately with a trained and trusted peer officer and to then seek professional help if necessary, said Dr. Violanti.

The study was funded by a grant from the National Institute of Occupational Health and Safety. Dr. Jetelina, Dr. Ng, and Dr. Violanti disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

New research shows that about a quarter of police officers in one large force report past or present mental health problems.

Responding to a survey, 26% of police officers on the Dallas police department screened positive for depression, anxiety, PTSD, or symptoms of suicide ideation or self-harm.

Mental illness rates were particularly high among female officers, those who were divorced, widowed, or separated, and those with military experience.

The study also showed that concerns over confidentiality and stigma may prevent officers with mental illness from seeking treatment.

The results underscored the need to identify police officers with psychiatric problems and to connect them to the most appropriate individualized care, author Katelyn K. Jetelina, PhD, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.

“This is a very hard-to-reach population, and because of that, we need to be innovative in reaching them for services,” she said.

The study was published online Oct. 7 in JAMA Network Open.

Dr. Jetelina and colleagues are investigating various aspects of police officers’ well-being, including their nutritional needs and their occupational, physical, and mental health.

The current study included 434 members of the Dallas police department, the ninth largest in the United States. The mean age of the participants was 37 years, 82% were men, and about half were White. The 434 officers represented 97% of those invited to participate (n = 446) and 31% of the total patrol population of the Dallas police department (n = 1,413).

These officers completed a short survey on their smartphone that asked about lifetime diagnoses of depression, anxiety, and PTSD. They were also asked whether they experienced suicidal ideation or self-harm during the previous 2 weeks.

Overall, 12% of survey respondents reported having been diagnosed with a mental illness. This, said Jetelina, is slightly lower than the rate reported in the general population.

Study participants who had not currently been diagnosed with a mental illness completed the Patient Health Questionnaire–2 (PHQ-2), the Generalized Anxiety Disorder–2 (GAD-2), and the Primary Care–Posttraumatic Stress Disorder (PC-PTSD).

Officers were considered to have a positive result if they had a score of 3 or more (PHQ-2, sensitivity of 83% and specificity of 92%; PC-PTSD-5, sensitivity of 93% and specificity of 85%; GAD-2, sensitivity of 86% and specificity of 83%).

About 26% of respondents had a positive screening for mental illness symptoms, mainly PTSD and depression, which Dr. Jetelina noted is a higher percentage than in the general population.

This rate of mental health symptoms is “high and concerning,” but not surprising because of the work of police officers, which could include attending to sometimes violent car crashes, domestic abuse situations, and armed conflicts, said Dr. Jetelina.

“They’re constantly exposed to traumatic calls for service; they see people on their worst day, 8 hours a day, 5 days a week. That stress and exposure will have a detrimental effect on mental health, and we have to pay more attention to that,” she said.

Dr. Jetelina pointed out that the surveys were completed in January and February 2020, before COVID-19 had become a cause of stress for everyone and before the increase in calls for defunding police amid a resurgence of Black Lives Matter demonstrations.

However, she stressed that racial biases and occupational stress among police officers are “nothing new for them.” For example, in 2016, five Dallas police officers were killed during Black Lives Matter protests because of their race/ethnicity.
 

More at risk

The study showed that certain subgroups of officers were more at risk for mental illness. After adjustment for confounders, including demographic characteristics, marital status, and educational level, the odds of being diagnosed with a mental illness during the course of one’s life were significantly higher among female officers than male officers (adjusted odds ratio, 3.20; 95% confidence interval, 1.18-8.68).

Officers who were divorced, widowed, or separated and those who had more experience and held a higher rank were also at greater risk for mental illness.

As well, military veterans had greater odds of being diagnosed with a mental health disorder, compared with nonveterans (aOR, 3.25; 95% CI, 1.38-7.67).

The study also asked participants about use of mental health care services over the past 12 months. About 35% of those who had a current mental health diagnosis and 17% of those who screened positive for mental health symptoms reported using such services.

The study also asked those who screened positive about their interest in seeking such services. After adjustments, officers with suicidal ideation or self-harm were significantly more likely to be interested in getting help, compared with officers who did not report suicidal ideation or self-harm (aOR, 7.66; 95% CI, 1.70-34.48).

Dr. Jetelina was impressed that so many officers were keen to seek help, which “is a big positive,” she said. “It’s just a matter of better detecting who needs the help and better connecting them to medical services that meet their needs.”
 

Mindfulness exercise

Dr. Jetelina and colleagues are conducting a pilot test of the use by police officers of smartwatches that monitor heart rate and oxygen levels. If measurements with these devices reach a predetermined threshold, the officers are “pinged” and are instructed to perform a mindfulness exercise in the field, she said.

Results so far “are really exciting,” said Dr. Jetelina. “Officers have found this extremely helpful and feasible, and so the next step is to test if this truly impacts mental illness over time.”

Routine mental health screening of officers might be beneficial, but only if it’s conducted in a manner “respectful of the officers’ needs and wants,” said Dr. Jetelina.

She pointed out that although psychological assessments are routinely carried out following an extreme traumatic call, such as one involving an officer-involved shooting, the “in-between” calls could have a more severe cumulative impact on mental health.

It’s important to provide officers with easy-to-access services tailored for their individual needs, said Dr. Jetelina.
 

‘Numb to it’

Eighteen patrol officers also participated in a focus group, during which several themes regarding the use of mental health care services emerged. One theme was the inability of officers to identify when they’re personally experiencing a mental health problem.

Participants said they had become “numb” to the traumatic events on the job, which is “concerning,” Dr. Jetelina said. “They think that having nightmares every week is completely normal, but it’s not, and this needs to be addressed.”

Other themes that emerged from focus groups included the belief that psychologists can’t relate to police stressors; concerns about confidentiality (one sentiment that was expressed was “you’re an idiot” if you “trust this department”); and stigma for officers who seek mental health care (participants talked about “reprisal” from seeing “a shrink,” including being labeled as “a nutter” and losing their job).

Dr. Jetelina noted that some “champion” officers revealed their mental health journey during focus groups, which tended to “open a Pandora’s box” for others to discuss their experience. She said these champions could be leveraged throughout the police department to help reduce stigma.

The study included participants from only one police department, although rigorous data collection allows for generalizability to the entire patrol department, say the authors. Although the study included only brief screens of mental illness symptoms, these short versions of screening tests have high sensitivity and specificity for mental illness in primary care, they noted.

The next step for the researchers is to study how mental illness and symptoms affect job performance, said Dr. Jetelina. “Does this impact excessive use of force? Does this impact workers’ compensation? Does this impact dispatch times, the time it takes for a police officer to respond to [a] 911 call?”
 

Possible underrepresentation

Anthony T. Ng, MD, regional medical director, East Region Hartford HealthCare Behavioral Health Network in Mansfield, Conn., and member of the American Psychiatric Association’s Council on Communications, found the study “helpful.”

However, the 26% who tested positive for mental illness may be an “underrepresentation” of the true picture, inasmuch as police officers might minimize or be less than truthful about their mental health status, said Dr. Ng.

Law enforcement has “never been easy,” but stressors may have escalated recently as police forces deal with shortages of staff and jails, said Dr. Ng.

He also noted that officers might face stressors at home. “Evidence shows that domestic violence is quite high – or higher than average – among law enforcement,” he said. “All these things add up.”

Psychiatrists and other mental health professionals should be “aware of the unique challenges” that police officers face and be “proactively involved” in providing guidance and education on mitigating stress, said Dr. Ng.

“You have police officers wearing body armor, so why can’t you give them some training to learn how to have psychiatric or psychological body armor?” he said. But it’s a two-way street; police forces should be open to outreach from mental health professionals. “We have to meet halfway.”
 

Compassion fatigue

In an accompanying commentary, John M. Violanti, PhD, of the department of epidemiology and environmental health at the State University of New York at Buffalo, said the article helps bring “to the forefront” the issue of the psychological dangers of police work.

There is conjecture as to why police experience mental distress, said Dr. Violanti, who pointed to a study of New York City police suicides during the 1930s that suggested that police have a “social license” for aggressive behavior but are restrained as part of public trust, placing them in a position of “psychological strain.”

“This situation may be reflective of the same situation police find themselves today,” said Dr. Violanti.

“Compassion fatigue,” a feeling of mental exhaustion caused by the inability to care for all persons in trouble, may also be a factor, as could the constant stress that leaves police officers feeling “cynical and isolated from others,” he wrote.

“The socialization process of becoming a police officer is associated with constrictive reasoning, viewing the world as either right or wrong, which leaves no middle ground for alternatives to deal with mental distress,” Dr. Violanti said.

He noted that police officers may abuse alcohol because of stress, peer pressure, isolation, and a culture that approves of alcohol use. “Officers tend to drink together and reinforce their own values.”.

Although no prospective studies have linked police mental health problems with childhood abuse or neglect, some mental health professionals estimate that about 25% of their police clients have a history of childhood abuse or neglect, said Dr. Violanti.

He agreed that mindfulness may help manage stress and increase cognitive flexibility in dealing with trauma and crises.

A possible way to ensure confidentiality is a peer support program that allows distressed officers to first talk privately with a trained and trusted peer officer and to then seek professional help if necessary, said Dr. Violanti.

The study was funded by a grant from the National Institute of Occupational Health and Safety. Dr. Jetelina, Dr. Ng, and Dr. Violanti disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Gender-incongruent youth who present for gender-affirming medical care later in adolescence have higher rates of mental health problems than their younger counterparts, based on data from a review of 300 individuals.

Peerayot/Thinkstock.com

“Puberty is a vulnerable time for youth with gender dysphoria because distress may intensify with the development of secondary sex characteristics corresponding to the assigned rather than the experienced gender,” wrote Julia C. Sorbara, MD, of the University of Toronto and the Hospital for Sick Children, also in Toronto, and colleagues.

Although gender-affirming medical care (GAMC) in the form of hormone blockers and/or gender-affirming hormones early in puberty can decrease in emotional and behavioral problems, many teens present later in puberty, and the relationship between pubertal stage at presentation for treatment and mental health has not been examined, they wrote.

In a study published in Pediatrics, the researchers reviewed data from youth with gender incongruence who were seen at a single center; 116 were younger than 15 years at presentation for GAMC and were defined as younger-presenting youth (YPY), and 184 patients aged 15 years and older were defined as older-presenting youth (OPY).

Overall, 78% of the youth reported at least one mental health problem at their initial visit. Significantly more OPY than YPY reported diagnosed depression (46% vs. 30%), self-harm (40% vs. 28%), suicidal thoughts (52% vs. 40%), suicide attempts (17% vs. 9%), and use of psychoactive medications (36% vs. 23%), all with P < .05.

In a multivariate analysis, patients in Tanner stages 4 and 5 were five times more likely to experience depressive disorders (odds ratio, 5.49) and four times as likely to experience depressive disorders (OR, 4.18) as those in earlier Tanner stages. Older age remained significantly associated with use of psychoactive medications (OR, 1.31), but not with anxiety or depression, the researchers wrote.

The YPY group were significantly younger at the age of recognizing gender incongruence, compared with the OPY group, with median ages at recognition of 5.8 years and 9 years, respectively, and younger patients came out about their gender identity at an average of 12 years, compared with 15 years for older patients.

The quantitative data are among the first to relate pubertal stage to mental health in gender-incongruent youth, “supporting clinical observations that pubertal development, menses, and erections are distressing to these youth and consistent with the beneficial role of pubertal suppression, even when used as monotherapy without gender-affirming hormones,” Dr. Sorbara and associates wrote.

The study findings were limited by several factors including the cross-sectional design and the collection of mental health data at only one time point and by the use of self-reports. However, the results suggest that “[gender-incongruent] youth who present to GAMC later in life are a particularly high-risk subset of a vulnerable population,” they noted. “Further study is required to better describe the mental health trajectories of transgender youth and determine if mental health status or age at initiation of GAMC is correlated with psychological well-being in adulthood.”
 

Don’t rush to puberty suppression in younger teens

To reduce the stress of puberty on gender-nonconforming youth, puberty suppression as “a reversible medical intervention” was introduced by Dutch clinicians in the early 2000s, Annelou L.C. de Vries, MD, PhD, of Amsterdam University Medical Center, wrote in an accompanying editorial.

“The aim of puberty suppression was to prevent the psychological suffering stemming from undesired physical changes when puberty starts and allowing the adolescent time to make plans regarding further transition or not,” Dr. de Vries said. “Following this rationale, younger age at the time of starting medical-affirming treatment (puberty suppression or hormones) would be expected to correlate with fewer psychological difficulties related to physical changes than older individuals,” which was confirmed in the current study.

However, clinicians should be cautious in offering puberty suppression at a younger age, in part because “despite the increased availability of gender-affirming medical interventions for younger ages in recent years, there has not been a proportional decline in older presenting youth with gender incongruence,” she said.

More data are needed on youth with postpuberty adolescent-onset transgender histories. The original Dutch studies on gender-affirming medical interventions note case histories describing “the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition,” Dr. de Vries explained.

Ultimately, prospective studies with longer follow-up data are needed to better inform clinicians in developing an individualized treatment plan for youth with gender incongruence, Dr. de Vries concluded.
 

Care barriers can include parents, access, insurance

The study authors describe the situation of gender-affirming medical care in teens perfectly, M. Brett Cooper, MD, of the University of Texas Southwestern Medical Center/Children’s Health Dallas, said in an interview.

Given a variety of factors that need further exploration, “many youth often don’t end up seeking gender-affirming medical care until puberty has progressed to near full maturity,” he said. “The findings from this study provide preliminary evidence to show that if we can identify these youth earlier in their gender journey, we might be able to impact adverse mental health outcomes in a positive way.”

Dr. Cooper said he was not surprised by the study findings. “They are similar to what I see in my clinic.

“Many of our patients often don’t present for medical care until around age 15 or older, similar to the findings of the study,” he added. “The majority of our patients have had a diagnosis of anxiety or depression at some point in their lifetime, including inpatient hospitalizations for their mental health.”

One of the most important barriers to care often can be parents or guardians, said Dr. Cooper. “Young people usually know their gender identity by about age 4-5 but parents may think that a gender-diverse identity could simply be a ‘phase.’ Other times, young people may hide their identity out of fear of a negative reaction from their parents. The distress around identity may become more pronounced once pubertal changes, such as breast and testicle development, begin to worsen their dysphoria.”

“Another barrier to care can be the inability to find a competent, gender-affirming provider,” Dr. Cooper said. “Most large United States cities have at least one gender-affirming clinic, but for those youth who grow up in smaller towns, it may be difficult to access these clinics. In addition, some clinics require a letter from a therapist stating that the young person is transgender before they can be seen for medical care. This creates an access barrier, as it may be difficult not just to find a therapist but one who has experience working with gender-diverse youth.”

Insurance coverage, including lack thereof, is yet another barrier to care for transgender youth, said Dr. Cooper. “While many insurance companies have begun to cover medications such as testosterone and estrogen for gender-affirming care, many still have exclusions on things like puberty blockers and surgical interventions.” These interventions can be lifesaving, but financially prohibitive for many families if not covered by insurance.

As for the value of early timing of gender-affirming care, Dr. Cooper agreed with the study findings that the earlier that a young person can get into medical care for their gender identity, the better chance there is to reduce the prevalence of serious mental health outcomes. “This also prevents the potential development of secondary sexual characteristics, decreasing the need for or amount of surgery in the future if desired,” he said.

“More research is needed to better understand the reasons why many youth don’t present to care until later in puberty. In addition, we need better research on interventions that are effective at reducing serious mental health events in transgender and gender diverse youth,” Dr. Cooper stated. “Another area that I would like to see researched is looking at the mental health of non-Caucasian youth. As the authors noted in their study, many clinics have a high percentage of patients presenting for care who identify as White or Caucasian, and we need to better understand why these other youth are not presenting for care.”

The study received no outside funding. Dr. Sorbara disclosed salary support from the Canadian Pediatric Endocrine Group fellowship program. Dr. de Vries had no financial conflicts to disclose. Dr. Cooper had no financial conflicts to disclose, and serves as a contributor to LGBTQ Youth Consult in Pediatric News.

SOURCES: Sorbara JC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2019-3600; de Vries ALC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2020-010611.

Gender-incongruent youth who present for gender-affirming medical care later in adolescence have higher rates of mental health problems than their younger counterparts, based on data from a review of 300 individuals.

Peerayot/Thinkstock.com

“Puberty is a vulnerable time for youth with gender dysphoria because distress may intensify with the development of secondary sex characteristics corresponding to the assigned rather than the experienced gender,” wrote Julia C. Sorbara, MD, of the University of Toronto and the Hospital for Sick Children, also in Toronto, and colleagues.

Although gender-affirming medical care (GAMC) in the form of hormone blockers and/or gender-affirming hormones early in puberty can decrease in emotional and behavioral problems, many teens present later in puberty, and the relationship between pubertal stage at presentation for treatment and mental health has not been examined, they wrote.

In a study published in Pediatrics, the researchers reviewed data from youth with gender incongruence who were seen at a single center; 116 were younger than 15 years at presentation for GAMC and were defined as younger-presenting youth (YPY), and 184 patients aged 15 years and older were defined as older-presenting youth (OPY).

Overall, 78% of the youth reported at least one mental health problem at their initial visit. Significantly more OPY than YPY reported diagnosed depression (46% vs. 30%), self-harm (40% vs. 28%), suicidal thoughts (52% vs. 40%), suicide attempts (17% vs. 9%), and use of psychoactive medications (36% vs. 23%), all with P < .05.

In a multivariate analysis, patients in Tanner stages 4 and 5 were five times more likely to experience depressive disorders (odds ratio, 5.49) and four times as likely to experience depressive disorders (OR, 4.18) as those in earlier Tanner stages. Older age remained significantly associated with use of psychoactive medications (OR, 1.31), but not with anxiety or depression, the researchers wrote.

The YPY group were significantly younger at the age of recognizing gender incongruence, compared with the OPY group, with median ages at recognition of 5.8 years and 9 years, respectively, and younger patients came out about their gender identity at an average of 12 years, compared with 15 years for older patients.

The quantitative data are among the first to relate pubertal stage to mental health in gender-incongruent youth, “supporting clinical observations that pubertal development, menses, and erections are distressing to these youth and consistent with the beneficial role of pubertal suppression, even when used as monotherapy without gender-affirming hormones,” Dr. Sorbara and associates wrote.

The study findings were limited by several factors including the cross-sectional design and the collection of mental health data at only one time point and by the use of self-reports. However, the results suggest that “[gender-incongruent] youth who present to GAMC later in life are a particularly high-risk subset of a vulnerable population,” they noted. “Further study is required to better describe the mental health trajectories of transgender youth and determine if mental health status or age at initiation of GAMC is correlated with psychological well-being in adulthood.”
 

Don’t rush to puberty suppression in younger teens

To reduce the stress of puberty on gender-nonconforming youth, puberty suppression as “a reversible medical intervention” was introduced by Dutch clinicians in the early 2000s, Annelou L.C. de Vries, MD, PhD, of Amsterdam University Medical Center, wrote in an accompanying editorial.

“The aim of puberty suppression was to prevent the psychological suffering stemming from undesired physical changes when puberty starts and allowing the adolescent time to make plans regarding further transition or not,” Dr. de Vries said. “Following this rationale, younger age at the time of starting medical-affirming treatment (puberty suppression or hormones) would be expected to correlate with fewer psychological difficulties related to physical changes than older individuals,” which was confirmed in the current study.

However, clinicians should be cautious in offering puberty suppression at a younger age, in part because “despite the increased availability of gender-affirming medical interventions for younger ages in recent years, there has not been a proportional decline in older presenting youth with gender incongruence,” she said.

More data are needed on youth with postpuberty adolescent-onset transgender histories. The original Dutch studies on gender-affirming medical interventions note case histories describing “the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition,” Dr. de Vries explained.

Ultimately, prospective studies with longer follow-up data are needed to better inform clinicians in developing an individualized treatment plan for youth with gender incongruence, Dr. de Vries concluded.
 

Care barriers can include parents, access, insurance

The study authors describe the situation of gender-affirming medical care in teens perfectly, M. Brett Cooper, MD, of the University of Texas Southwestern Medical Center/Children’s Health Dallas, said in an interview.

Given a variety of factors that need further exploration, “many youth often don’t end up seeking gender-affirming medical care until puberty has progressed to near full maturity,” he said. “The findings from this study provide preliminary evidence to show that if we can identify these youth earlier in their gender journey, we might be able to impact adverse mental health outcomes in a positive way.”

Dr. Cooper said he was not surprised by the study findings. “They are similar to what I see in my clinic.

“Many of our patients often don’t present for medical care until around age 15 or older, similar to the findings of the study,” he added. “The majority of our patients have had a diagnosis of anxiety or depression at some point in their lifetime, including inpatient hospitalizations for their mental health.”

One of the most important barriers to care often can be parents or guardians, said Dr. Cooper. “Young people usually know their gender identity by about age 4-5 but parents may think that a gender-diverse identity could simply be a ‘phase.’ Other times, young people may hide their identity out of fear of a negative reaction from their parents. The distress around identity may become more pronounced once pubertal changes, such as breast and testicle development, begin to worsen their dysphoria.”

“Another barrier to care can be the inability to find a competent, gender-affirming provider,” Dr. Cooper said. “Most large United States cities have at least one gender-affirming clinic, but for those youth who grow up in smaller towns, it may be difficult to access these clinics. In addition, some clinics require a letter from a therapist stating that the young person is transgender before they can be seen for medical care. This creates an access barrier, as it may be difficult not just to find a therapist but one who has experience working with gender-diverse youth.”

Insurance coverage, including lack thereof, is yet another barrier to care for transgender youth, said Dr. Cooper. “While many insurance companies have begun to cover medications such as testosterone and estrogen for gender-affirming care, many still have exclusions on things like puberty blockers and surgical interventions.” These interventions can be lifesaving, but financially prohibitive for many families if not covered by insurance.

As for the value of early timing of gender-affirming care, Dr. Cooper agreed with the study findings that the earlier that a young person can get into medical care for their gender identity, the better chance there is to reduce the prevalence of serious mental health outcomes. “This also prevents the potential development of secondary sexual characteristics, decreasing the need for or amount of surgery in the future if desired,” he said.

“More research is needed to better understand the reasons why many youth don’t present to care until later in puberty. In addition, we need better research on interventions that are effective at reducing serious mental health events in transgender and gender diverse youth,” Dr. Cooper stated. “Another area that I would like to see researched is looking at the mental health of non-Caucasian youth. As the authors noted in their study, many clinics have a high percentage of patients presenting for care who identify as White or Caucasian, and we need to better understand why these other youth are not presenting for care.”

The study received no outside funding. Dr. Sorbara disclosed salary support from the Canadian Pediatric Endocrine Group fellowship program. Dr. de Vries had no financial conflicts to disclose. Dr. Cooper had no financial conflicts to disclose, and serves as a contributor to LGBTQ Youth Consult in Pediatric News.

SOURCES: Sorbara JC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2019-3600; de Vries ALC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2020-010611.

Gender-incongruent youth who present for gender-affirming medical care later in adolescence have higher rates of mental health problems than their younger counterparts, based on data from a review of 300 individuals.

Peerayot/Thinkstock.com

“Puberty is a vulnerable time for youth with gender dysphoria because distress may intensify with the development of secondary sex characteristics corresponding to the assigned rather than the experienced gender,” wrote Julia C. Sorbara, MD, of the University of Toronto and the Hospital for Sick Children, also in Toronto, and colleagues.

Although gender-affirming medical care (GAMC) in the form of hormone blockers and/or gender-affirming hormones early in puberty can decrease in emotional and behavioral problems, many teens present later in puberty, and the relationship between pubertal stage at presentation for treatment and mental health has not been examined, they wrote.

In a study published in Pediatrics, the researchers reviewed data from youth with gender incongruence who were seen at a single center; 116 were younger than 15 years at presentation for GAMC and were defined as younger-presenting youth (YPY), and 184 patients aged 15 years and older were defined as older-presenting youth (OPY).

Overall, 78% of the youth reported at least one mental health problem at their initial visit. Significantly more OPY than YPY reported diagnosed depression (46% vs. 30%), self-harm (40% vs. 28%), suicidal thoughts (52% vs. 40%), suicide attempts (17% vs. 9%), and use of psychoactive medications (36% vs. 23%), all with P < .05.

In a multivariate analysis, patients in Tanner stages 4 and 5 were five times more likely to experience depressive disorders (odds ratio, 5.49) and four times as likely to experience depressive disorders (OR, 4.18) as those in earlier Tanner stages. Older age remained significantly associated with use of psychoactive medications (OR, 1.31), but not with anxiety or depression, the researchers wrote.

The YPY group were significantly younger at the age of recognizing gender incongruence, compared with the OPY group, with median ages at recognition of 5.8 years and 9 years, respectively, and younger patients came out about their gender identity at an average of 12 years, compared with 15 years for older patients.

The quantitative data are among the first to relate pubertal stage to mental health in gender-incongruent youth, “supporting clinical observations that pubertal development, menses, and erections are distressing to these youth and consistent with the beneficial role of pubertal suppression, even when used as monotherapy without gender-affirming hormones,” Dr. Sorbara and associates wrote.

The study findings were limited by several factors including the cross-sectional design and the collection of mental health data at only one time point and by the use of self-reports. However, the results suggest that “[gender-incongruent] youth who present to GAMC later in life are a particularly high-risk subset of a vulnerable population,” they noted. “Further study is required to better describe the mental health trajectories of transgender youth and determine if mental health status or age at initiation of GAMC is correlated with psychological well-being in adulthood.”
 

Don’t rush to puberty suppression in younger teens

To reduce the stress of puberty on gender-nonconforming youth, puberty suppression as “a reversible medical intervention” was introduced by Dutch clinicians in the early 2000s, Annelou L.C. de Vries, MD, PhD, of Amsterdam University Medical Center, wrote in an accompanying editorial.

“The aim of puberty suppression was to prevent the psychological suffering stemming from undesired physical changes when puberty starts and allowing the adolescent time to make plans regarding further transition or not,” Dr. de Vries said. “Following this rationale, younger age at the time of starting medical-affirming treatment (puberty suppression or hormones) would be expected to correlate with fewer psychological difficulties related to physical changes than older individuals,” which was confirmed in the current study.

However, clinicians should be cautious in offering puberty suppression at a younger age, in part because “despite the increased availability of gender-affirming medical interventions for younger ages in recent years, there has not been a proportional decline in older presenting youth with gender incongruence,” she said.

More data are needed on youth with postpuberty adolescent-onset transgender histories. The original Dutch studies on gender-affirming medical interventions note case histories describing “the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition,” Dr. de Vries explained.

Ultimately, prospective studies with longer follow-up data are needed to better inform clinicians in developing an individualized treatment plan for youth with gender incongruence, Dr. de Vries concluded.
 

Care barriers can include parents, access, insurance

The study authors describe the situation of gender-affirming medical care in teens perfectly, M. Brett Cooper, MD, of the University of Texas Southwestern Medical Center/Children’s Health Dallas, said in an interview.

Given a variety of factors that need further exploration, “many youth often don’t end up seeking gender-affirming medical care until puberty has progressed to near full maturity,” he said. “The findings from this study provide preliminary evidence to show that if we can identify these youth earlier in their gender journey, we might be able to impact adverse mental health outcomes in a positive way.”

Dr. Cooper said he was not surprised by the study findings. “They are similar to what I see in my clinic.

“Many of our patients often don’t present for medical care until around age 15 or older, similar to the findings of the study,” he added. “The majority of our patients have had a diagnosis of anxiety or depression at some point in their lifetime, including inpatient hospitalizations for their mental health.”

One of the most important barriers to care often can be parents or guardians, said Dr. Cooper. “Young people usually know their gender identity by about age 4-5 but parents may think that a gender-diverse identity could simply be a ‘phase.’ Other times, young people may hide their identity out of fear of a negative reaction from their parents. The distress around identity may become more pronounced once pubertal changes, such as breast and testicle development, begin to worsen their dysphoria.”

“Another barrier to care can be the inability to find a competent, gender-affirming provider,” Dr. Cooper said. “Most large United States cities have at least one gender-affirming clinic, but for those youth who grow up in smaller towns, it may be difficult to access these clinics. In addition, some clinics require a letter from a therapist stating that the young person is transgender before they can be seen for medical care. This creates an access barrier, as it may be difficult not just to find a therapist but one who has experience working with gender-diverse youth.”

Insurance coverage, including lack thereof, is yet another barrier to care for transgender youth, said Dr. Cooper. “While many insurance companies have begun to cover medications such as testosterone and estrogen for gender-affirming care, many still have exclusions on things like puberty blockers and surgical interventions.” These interventions can be lifesaving, but financially prohibitive for many families if not covered by insurance.

As for the value of early timing of gender-affirming care, Dr. Cooper agreed with the study findings that the earlier that a young person can get into medical care for their gender identity, the better chance there is to reduce the prevalence of serious mental health outcomes. “This also prevents the potential development of secondary sexual characteristics, decreasing the need for or amount of surgery in the future if desired,” he said.

“More research is needed to better understand the reasons why many youth don’t present to care until later in puberty. In addition, we need better research on interventions that are effective at reducing serious mental health events in transgender and gender diverse youth,” Dr. Cooper stated. “Another area that I would like to see researched is looking at the mental health of non-Caucasian youth. As the authors noted in their study, many clinics have a high percentage of patients presenting for care who identify as White or Caucasian, and we need to better understand why these other youth are not presenting for care.”

The study received no outside funding. Dr. Sorbara disclosed salary support from the Canadian Pediatric Endocrine Group fellowship program. Dr. de Vries had no financial conflicts to disclose. Dr. Cooper had no financial conflicts to disclose, and serves as a contributor to LGBTQ Youth Consult in Pediatric News.

SOURCES: Sorbara JC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2019-3600; de Vries ALC et al. Pediatrics. 2020 Sep 21. doi: 10.1542/peds.2020-010611.

Depression or an anxiety disorder in male adolescents was associated with a 20% increased likelihood of experiencing an acute MI in midlife in a Swedish national registry study presented at the virtual annual congress of the European Society of Cardiology.

The association was mediated in part by poor stress resilience and lack of physical fitness among these teenagers with an affective disorder, reported Cecilia Bergh, PhD, of Obrero (Sweden) University.

Her study was made possible by Sweden’s comprehensive national health care registries coupled with the Nordic nation’s compulsory conscription for military service. The mandatory conscription evaluation during the study years included a semistructured interview with a psychologist to assess stress resilience through questions about coping with everyday life, a medical history and physical examination, and a cardiovascular fitness test using a bicycle ergometer.

The study included 238,013 males born in 1952-1956. They were aged 18-19 years when they underwent their conscription examination, at which time 34,503 of them either received or already had a diagnosis of depression or anxiety. During follow-up from 1987 to 2010, a first acute MI occurred in 5,891 of the men. The risk was increased 51% among those with an earlier teen diagnosis of depression or anxiety.

In a Cox regression analysis adjusted for levels of adolescent cardiovascular risk factors, including blood pressure, body mass index, and systemic inflammation, as well as additional potential confounders, such as cognitive function, parental socioeconomic index, and a summary disease score, the midlife MI risk associated with adolescent depression or anxiety was attenuated, but still significant, with a 24% increase. Upon further statistical adjustment incorporating adolescent stress resilience and cardiovascular fitness, the increased risk of acute MI in midlife associated with adolescent depression or anxiety was further attenuated yet remained significant, at 18%.

Dr. Bergh shared her thoughts on preventing this increased risk of acute MI at a relatively young age: “Effective prevention might focus on behavior, lifestyle, and psychosocial stress in early life. If a healthy lifestyle is encouraged as early as possible in childhood and adolescence, it is more likely to persist into adulthood and to improve longterm health. So look for signs of stress, depression, or anxiety that is beyond normal teenager behavior and a persistent problem. Teenagers with poor well-being could benefit from additional support to encourage exercise and also to develop strategies to deal with stress.”

She reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Bergh C et al. ESC 2020, Abstract 90524.

Depression or an anxiety disorder in male adolescents was associated with a 20% increased likelihood of experiencing an acute MI in midlife in a Swedish national registry study presented at the virtual annual congress of the European Society of Cardiology.

The association was mediated in part by poor stress resilience and lack of physical fitness among these teenagers with an affective disorder, reported Cecilia Bergh, PhD, of Obrero (Sweden) University.

Her study was made possible by Sweden’s comprehensive national health care registries coupled with the Nordic nation’s compulsory conscription for military service. The mandatory conscription evaluation during the study years included a semistructured interview with a psychologist to assess stress resilience through questions about coping with everyday life, a medical history and physical examination, and a cardiovascular fitness test using a bicycle ergometer.

The study included 238,013 males born in 1952-1956. They were aged 18-19 years when they underwent their conscription examination, at which time 34,503 of them either received or already had a diagnosis of depression or anxiety. During follow-up from 1987 to 2010, a first acute MI occurred in 5,891 of the men. The risk was increased 51% among those with an earlier teen diagnosis of depression or anxiety.

In a Cox regression analysis adjusted for levels of adolescent cardiovascular risk factors, including blood pressure, body mass index, and systemic inflammation, as well as additional potential confounders, such as cognitive function, parental socioeconomic index, and a summary disease score, the midlife MI risk associated with adolescent depression or anxiety was attenuated, but still significant, with a 24% increase. Upon further statistical adjustment incorporating adolescent stress resilience and cardiovascular fitness, the increased risk of acute MI in midlife associated with adolescent depression or anxiety was further attenuated yet remained significant, at 18%.

Dr. Bergh shared her thoughts on preventing this increased risk of acute MI at a relatively young age: “Effective prevention might focus on behavior, lifestyle, and psychosocial stress in early life. If a healthy lifestyle is encouraged as early as possible in childhood and adolescence, it is more likely to persist into adulthood and to improve longterm health. So look for signs of stress, depression, or anxiety that is beyond normal teenager behavior and a persistent problem. Teenagers with poor well-being could benefit from additional support to encourage exercise and also to develop strategies to deal with stress.”

She reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Bergh C et al. ESC 2020, Abstract 90524.

Depression or an anxiety disorder in male adolescents was associated with a 20% increased likelihood of experiencing an acute MI in midlife in a Swedish national registry study presented at the virtual annual congress of the European Society of Cardiology.

The association was mediated in part by poor stress resilience and lack of physical fitness among these teenagers with an affective disorder, reported Cecilia Bergh, PhD, of Obrero (Sweden) University.

Her study was made possible by Sweden’s comprehensive national health care registries coupled with the Nordic nation’s compulsory conscription for military service. The mandatory conscription evaluation during the study years included a semistructured interview with a psychologist to assess stress resilience through questions about coping with everyday life, a medical history and physical examination, and a cardiovascular fitness test using a bicycle ergometer.

The study included 238,013 males born in 1952-1956. They were aged 18-19 years when they underwent their conscription examination, at which time 34,503 of them either received or already had a diagnosis of depression or anxiety. During follow-up from 1987 to 2010, a first acute MI occurred in 5,891 of the men. The risk was increased 51% among those with an earlier teen diagnosis of depression or anxiety.

In a Cox regression analysis adjusted for levels of adolescent cardiovascular risk factors, including blood pressure, body mass index, and systemic inflammation, as well as additional potential confounders, such as cognitive function, parental socioeconomic index, and a summary disease score, the midlife MI risk associated with adolescent depression or anxiety was attenuated, but still significant, with a 24% increase. Upon further statistical adjustment incorporating adolescent stress resilience and cardiovascular fitness, the increased risk of acute MI in midlife associated with adolescent depression or anxiety was further attenuated yet remained significant, at 18%.

Dr. Bergh shared her thoughts on preventing this increased risk of acute MI at a relatively young age: “Effective prevention might focus on behavior, lifestyle, and psychosocial stress in early life. If a healthy lifestyle is encouraged as early as possible in childhood and adolescence, it is more likely to persist into adulthood and to improve longterm health. So look for signs of stress, depression, or anxiety that is beyond normal teenager behavior and a persistent problem. Teenagers with poor well-being could benefit from additional support to encourage exercise and also to develop strategies to deal with stress.”

She reported having no financial conflicts regarding her study, conducted free of commercial support.

[email protected]

SOURCE: Bergh C et al. ESC 2020, Abstract 90524.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

Successful athletes exhibit positive mental health. This mental health is directly related to athletic success and high levels of performance.¹ Mental skills are as important as natural physical ability and mechanical skills in the sport of tennis.

Research has shown that tennis is 85% mental and that players spend 80% of their time on the court handling emotions. Some players look good in practice when they are not under pressure but cannot win matches (they have the physical skill level to win) because they cannot handle their own emotions during the duress of a match. They are affected by anger, fear, stress, poor concentration, and other internal elements that interfere with their ability to perform at an optimal level. Competitors may also be affected by external factors such as the sun, wind, an opponent, and so on, and may use these situations as an excuse not to win.

Players normally practice physical skills but rarely practice cognitive techniques. Regardless of level of play – pro, collegiate, junior, or club – practicing mental skills will greatly improve the players’ arsenal of weapons, giving them an edge in matches and making them the best players they can be. Mental health professionals also can use these strategies to help motivate athletes who compete in other sports – and in other competitive endeavors.

Visualization is the formation of a mental image of something of your choice. Visualization imagery techniques can be used by players to calm themselves before playing a match so their emotions are not wasted on trying to quiet the minds and quell stress. Implementing the following visualization techniques will reduce a player’s anxiety during the match, allowing the player to direct energy toward optimal mental and physical performance on the court.

In advance of a match, encourage the player to learn and analyze the opponent’s strengths and weaknesses by watching the opponent play and/or from asking others. The night before the scheduled match, get the player to imagine how they will play points against their competitor. Play into the opponents’ vulnerabilities or first play to their strengths to expose shortcomings and – then attack their weakness. For example, if an opponent has a weak backhand, first play to the opponent’s forehand and, when the opponent is vulnerable, go into his backhand to get a short or weak ball – and attack. The following are specific strategies that mental health professionals who work with athletes can use to help them perform optimally.
 

Using visualization, shadowing

Visualize the correct way to hit a tennis stroke and repeat it over and over in your mind. On a tennis court or where ever you have adequate space, shadow a stroke by using a racket and repetitively performing the actual stroke without hitting a ball. At home, practice relaxation and deep breathing techniques at night before going to sleep. Put yourself in a relaxed state and visualize repetitively striking the ball correctly. The next time you actually hit the stroke, you will produce a better shot.

Focusing on, staying in the here and now

The “here” means to focus on what is happening on your own court, not what is happening on the court next to you. Players may be affected by external factors, such as the sun, wind, and their opponent and may use these conditions or situations as an excuse if they do not win. Ignore background chatter and distractions, and be a horse with blinders. Be responsible for yourself and your own actions; manage what you can and realize that you cannot control the weather or actions of your opponent.

The “now” refers to staying present and focusing only on the current point. Do not think of past mistakes. If you are winning a match, do not think about celebrating while the match is still in play. If you are losing, do not start to write a script of excuses why you lost the match. Instead, just concentrate on the present, point by point. Focusing will allow you to understand what is true and important in the here and now. Focusing will help alleviate stress and better equip you to make quick decisions and be clear about your intended actions.
 

Set realistic and achievable goals

It is always good to have goals and dreams; however, you as a player must understand the realities of your current level of play. Know your level; don’t be grandiose and think you are able to beat Rafael Nadal. Having an unrealistic attitude will result in frustration and poor performance during a match. Instead, set achievable, and realistic short- and long-term goals for yourself, which will aid in your overall tennis development. After the match is over, reflect upon and evaluate the points – and your overall performance.

Don’t devalue yourself if you lose a match. Do not feel too low from a loss or too high from a win. When you have a match loss, use it as an opportunity to learn from your mistakes and to improve by working on your weaknesses in future practice until you feel confident enough to use your new skills in a tournament.
 

Stay positive

Do not tie up your self-esteem as a person with your match outcome; in otherwords, separate feelings of self-worth from your match results. Cultivate an optimistic attitude and talk positively to yourself, strive to improve, and maintain positive self-esteem in practice and in matches. During practice, allocate 110% effort, and focus on the process, not the outcome. Arrange your practice matches so that one-third of them are against players of your same level, one-third against players worse than you, and one-third against players better than yourself.

Deal with adversity

It is important to be able to deal with external pressures going on in your life such as conflicts related to family, peers, school, work, and relationships. Deal with and manage this discord before your match so you can maintain control of your emotions and can give 100% effort on the court.

Learn mental techniques

Many athletes may have difficulty teaching themselves cognitive skills and would benefit from a few sessions with a sports psychologist/psychiatrist to understand and learn the techniques. Once the tactics are understood and learned, players can apply them to training and ultimately to their tournament arsenal, allowing them to play to their ultimate potential.

References

1. Morgan WP. Selected psychological factors limiting performance: A mental health model. In Clarke DH and Eckert HM (eds.), Limits of Human Performance. Champaign, Ill.: Human Kinetics Publishers, 1985.

Dr. Cohen had a private practice in psychiatry for more than 35 years. He is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. Dr. Cohen has been a nationally ranked tennis player from age 12 to the present and served as captain of the tennis team at the University of Pennsylvania, Philadelphia. Dr. Cohen, who was ranked No. 1 in tennis in the middle states section and in the country in various categories and times, was inducted into the Philadelphia Jewish Sports Hall of Fame in 2012. Dr. Cohen has no conflicts of interest.

Ms. Cohen, Dr. Cohen’s daughter, was No. 1 ranked in the United States in junior tennis and No. 4 in the world. In addition, Ms. Cohen was ranked among the top 100 players in the world by the professional World Tennis Association. She also was the No. 2 college player in United States, and an All-American at the University of Miami. She holds a master’s in sports psychology, and presently works as a sports psychologist and tennis professional in Philadelphia. Ms. Cohen has no conflicts of interest.

Spain and China used very different public health responses to the COVID-19 crisis, and that has had significant consequences in terms of the mental health as well as physical health of the two countries’ citizens, Roger Ho, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
 

Dr. Ho, a psychiatrist at the National University of Singapore, presented a first-of-its-kind cross-cultural comparative study of the impact of the COVID-19 pandemic in two epicenters on opposite sides of the world. A total of 1,539 participants drawn from the general populations in the two countries completed the online National University of Singapore COVID-19 Questionnaire. The survey was conducted in late February/early March in China and in mid-April in Spain, times of intense disease activity in the countries.

The questionnaire assesses knowledge and concerns about COVID, precautionary measures taken in the last 14 days, contact history, and physical symptoms related to COVID in the last 14 days. The pandemic’s psychological impact was evaluated using the Impact of Event Scale–Revised (IES-R). Participants also completed the Depression, Anxiety, and Stress-21 Scale (DASS-21).

Of note, the pandemic has taken a vastly greater physical toll in Spain than China. As of May 5, there were 83,000 confirmed cases of COVID-19 in China, with a population of 1.39 billion, compared with 248,000 in Spain, with a population of 46.9 million. The Spanish case rate of 5,500 per 1 million population was 100 times greater than China’s; the Spanish mortality rate of 585 per million was 185-fold greater.
 

Mental health findings

Spaniards experienced significantly higher levels of stress and depression as reflected in DASS-21 subscale scores of 14.22 and 8.65, respectively, compared with 7.86 and 6.38, in Chinese respondents. Spanish subjects also reported greater anxiety levels than the Chinese on the DASS-21 anxiety subscale, although not to a statistically significant extent. Yet, counterintuitively, given the DASS-21 results, the pandemic had a greater adverse psychological impact on the Chinese subjects as reflected in their significantly higher average IES-D score of 30.76 versus 27.64 in Spain. Dr. Ho offered a hypothesis as to why: The survey documented that many Chinese respondents felt socially stigmatized, and that their nation had been discriminated against by the rest of the world because the pandemic started in China.

Satisfaction with the public health response

Spanish respondents reported less confidence in their COVID-related medical services.

“This could be due to the rising number of infected health care workers in Spain. In contrast, the Chinese had more confidence in their medical services, probably because the government quickly deployed medical personnel and treated COVID-19 patients at rapidly built hospitals,” according to Dr. Ho.

Spain and other European countries shared four shortcomings in their pandemic response, he continued: lack of personal protective equipment for health care workers, delay in developing response strategies, a shortage of hospital beds, and inability to protect vulnerable elderly individuals from infection in nursing homes.

Experiencing cough, shortness of breath, myalgia, or other physical symptoms potentially associated with COVID-19 within the past 14 days was associated with worse depression, anxiety, and stress scores in both China and Spain. This underscores from a mental health standpoint the importance of rapid and accurate testing for the infection, Dr. Ho said.

Significantly more Spanish respondents felt there was too much unnecessary worry about COVID-19, suggesting a need for better health education regarding the pandemic.
 

Use of face masks

Consistent use of face masks regardless of the presence or absence of symptoms was far more common in the Chinese epicenter, where, unlike in Spain, this precautionary measure was associated with significantly lower IES-R and DASS-21 scores.

“One of the important findings in our study is that wearing a face mask seems to protect the mental health in China, but for the Spanish, wearing a face mask was associated with higher IES-R scores,” Dr. Ho said. “We understand that it is difficult for Europeans to accept the need to use masks for healthy people because mask-wearing suggests vulnerability to sickness and concealment of identity. The Chinese have a collective culture. They believe they should wear a face mask to protect their health and that of other people.”

Dr. Ho reported no financial conflicts regarding his study, conducted with coinvestigators at Huaibei (China) Normal University and Complutense University of Madrid.
 

[email protected]

SOURCE: Ho R. ECNP 2020, Session ISE01.

Spain and China used very different public health responses to the COVID-19 crisis, and that has had significant consequences in terms of the mental health as well as physical health of the two countries’ citizens, Roger Ho, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
 

Dr. Ho, a psychiatrist at the National University of Singapore, presented a first-of-its-kind cross-cultural comparative study of the impact of the COVID-19 pandemic in two epicenters on opposite sides of the world. A total of 1,539 participants drawn from the general populations in the two countries completed the online National University of Singapore COVID-19 Questionnaire. The survey was conducted in late February/early March in China and in mid-April in Spain, times of intense disease activity in the countries.

The questionnaire assesses knowledge and concerns about COVID, precautionary measures taken in the last 14 days, contact history, and physical symptoms related to COVID in the last 14 days. The pandemic’s psychological impact was evaluated using the Impact of Event Scale–Revised (IES-R). Participants also completed the Depression, Anxiety, and Stress-21 Scale (DASS-21).

Of note, the pandemic has taken a vastly greater physical toll in Spain than China. As of May 5, there were 83,000 confirmed cases of COVID-19 in China, with a population of 1.39 billion, compared with 248,000 in Spain, with a population of 46.9 million. The Spanish case rate of 5,500 per 1 million population was 100 times greater than China’s; the Spanish mortality rate of 585 per million was 185-fold greater.
 

Mental health findings

Spaniards experienced significantly higher levels of stress and depression as reflected in DASS-21 subscale scores of 14.22 and 8.65, respectively, compared with 7.86 and 6.38, in Chinese respondents. Spanish subjects also reported greater anxiety levels than the Chinese on the DASS-21 anxiety subscale, although not to a statistically significant extent. Yet, counterintuitively, given the DASS-21 results, the pandemic had a greater adverse psychological impact on the Chinese subjects as reflected in their significantly higher average IES-D score of 30.76 versus 27.64 in Spain. Dr. Ho offered a hypothesis as to why: The survey documented that many Chinese respondents felt socially stigmatized, and that their nation had been discriminated against by the rest of the world because the pandemic started in China.

Satisfaction with the public health response

Spanish respondents reported less confidence in their COVID-related medical services.

“This could be due to the rising number of infected health care workers in Spain. In contrast, the Chinese had more confidence in their medical services, probably because the government quickly deployed medical personnel and treated COVID-19 patients at rapidly built hospitals,” according to Dr. Ho.

Spain and other European countries shared four shortcomings in their pandemic response, he continued: lack of personal protective equipment for health care workers, delay in developing response strategies, a shortage of hospital beds, and inability to protect vulnerable elderly individuals from infection in nursing homes.

Experiencing cough, shortness of breath, myalgia, or other physical symptoms potentially associated with COVID-19 within the past 14 days was associated with worse depression, anxiety, and stress scores in both China and Spain. This underscores from a mental health standpoint the importance of rapid and accurate testing for the infection, Dr. Ho said.

Significantly more Spanish respondents felt there was too much unnecessary worry about COVID-19, suggesting a need for better health education regarding the pandemic.
 

Use of face masks

Consistent use of face masks regardless of the presence or absence of symptoms was far more common in the Chinese epicenter, where, unlike in Spain, this precautionary measure was associated with significantly lower IES-R and DASS-21 scores.

“One of the important findings in our study is that wearing a face mask seems to protect the mental health in China, but for the Spanish, wearing a face mask was associated with higher IES-R scores,” Dr. Ho said. “We understand that it is difficult for Europeans to accept the need to use masks for healthy people because mask-wearing suggests vulnerability to sickness and concealment of identity. The Chinese have a collective culture. They believe they should wear a face mask to protect their health and that of other people.”

Dr. Ho reported no financial conflicts regarding his study, conducted with coinvestigators at Huaibei (China) Normal University and Complutense University of Madrid.
 

[email protected]

SOURCE: Ho R. ECNP 2020, Session ISE01.

Spain and China used very different public health responses to the COVID-19 crisis, and that has had significant consequences in terms of the mental health as well as physical health of the two countries’ citizens, Roger Ho, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
 

Dr. Ho, a psychiatrist at the National University of Singapore, presented a first-of-its-kind cross-cultural comparative study of the impact of the COVID-19 pandemic in two epicenters on opposite sides of the world. A total of 1,539 participants drawn from the general populations in the two countries completed the online National University of Singapore COVID-19 Questionnaire. The survey was conducted in late February/early March in China and in mid-April in Spain, times of intense disease activity in the countries.

The questionnaire assesses knowledge and concerns about COVID, precautionary measures taken in the last 14 days, contact history, and physical symptoms related to COVID in the last 14 days. The pandemic’s psychological impact was evaluated using the Impact of Event Scale–Revised (IES-R). Participants also completed the Depression, Anxiety, and Stress-21 Scale (DASS-21).

Of note, the pandemic has taken a vastly greater physical toll in Spain than China. As of May 5, there were 83,000 confirmed cases of COVID-19 in China, with a population of 1.39 billion, compared with 248,000 in Spain, with a population of 46.9 million. The Spanish case rate of 5,500 per 1 million population was 100 times greater than China’s; the Spanish mortality rate of 585 per million was 185-fold greater.
 

Mental health findings

Spaniards experienced significantly higher levels of stress and depression as reflected in DASS-21 subscale scores of 14.22 and 8.65, respectively, compared with 7.86 and 6.38, in Chinese respondents. Spanish subjects also reported greater anxiety levels than the Chinese on the DASS-21 anxiety subscale, although not to a statistically significant extent. Yet, counterintuitively, given the DASS-21 results, the pandemic had a greater adverse psychological impact on the Chinese subjects as reflected in their significantly higher average IES-D score of 30.76 versus 27.64 in Spain. Dr. Ho offered a hypothesis as to why: The survey documented that many Chinese respondents felt socially stigmatized, and that their nation had been discriminated against by the rest of the world because the pandemic started in China.

Satisfaction with the public health response

Spanish respondents reported less confidence in their COVID-related medical services.

“This could be due to the rising number of infected health care workers in Spain. In contrast, the Chinese had more confidence in their medical services, probably because the government quickly deployed medical personnel and treated COVID-19 patients at rapidly built hospitals,” according to Dr. Ho.

Spain and other European countries shared four shortcomings in their pandemic response, he continued: lack of personal protective equipment for health care workers, delay in developing response strategies, a shortage of hospital beds, and inability to protect vulnerable elderly individuals from infection in nursing homes.

Experiencing cough, shortness of breath, myalgia, or other physical symptoms potentially associated with COVID-19 within the past 14 days was associated with worse depression, anxiety, and stress scores in both China and Spain. This underscores from a mental health standpoint the importance of rapid and accurate testing for the infection, Dr. Ho said.

Significantly more Spanish respondents felt there was too much unnecessary worry about COVID-19, suggesting a need for better health education regarding the pandemic.
 

Use of face masks

Consistent use of face masks regardless of the presence or absence of symptoms was far more common in the Chinese epicenter, where, unlike in Spain, this precautionary measure was associated with significantly lower IES-R and DASS-21 scores.

“One of the important findings in our study is that wearing a face mask seems to protect the mental health in China, but for the Spanish, wearing a face mask was associated with higher IES-R scores,” Dr. Ho said. “We understand that it is difficult for Europeans to accept the need to use masks for healthy people because mask-wearing suggests vulnerability to sickness and concealment of identity. The Chinese have a collective culture. They believe they should wear a face mask to protect their health and that of other people.”

Dr. Ho reported no financial conflicts regarding his study, conducted with coinvestigators at Huaibei (China) Normal University and Complutense University of Madrid.
 

[email protected]

SOURCE: Ho R. ECNP 2020, Session ISE01.

During normal times, the U.K.-based charity No Panic offers itself as an easily accessible service to those with anxiety disorders and phobias. Visitors to the website who can receive immediate, remote support from trained volunteers. But this spring was anything but normal, as the reality of COVID-19’s worldwide spread became terrifyingly clear.

COVID-19 cases peaked in the United Kingdom in early April. Nationwide lockdown efforts contributed to a gradual but ultimately substantial decline in cases, yet, despite the favorable trend lines, No Panic has remained busier than ever.

Beyond the physical symptoms associated with COVID-19, the psychological outcomes are vast and, it seems, prolonged. Researchers have now formalized a definition of the long-term mental maladies associated with the pandemic, collectively deeming them “coronaphobia.”

The term is a catch-all phrase for the fear and the emotional and social strain experienced by the general public in response to COVID-19. Obsessive behaviors, distress, avoidance reaction, panic, anxiety, hoarding, paranoia, and depression are some of the responses associated with coronaphobia. On the surface, these appear to be normal, somewhat fitting reactions to this surreal and frightening moment in time. However, for those experiencing coronaphobia, they are distinctly maladaptive and harmful.

“We had a serious rise in the use of our services, notably the helpline and email enquiries,” explained Sarah Floyd, No Panic’s volunteer advisor and social media coordinator. “It has been up and down all along, but more of an up since lockdown is easing.”

The group’s experience offers yet more evidence that the anxieties and fears caused by this global pandemic don’t flatten alongside the curve but instead linger as chronic problems requiring ongoing care.

“Every week in my clinic, I’m seeing people who are experiencing more anxiety and hopelessness and having an emotional response that is perhaps out of proportion to what one would expect, which is directly related to what is going on in the world right now with coronavirus,” said Gregory Scott Brown, MD, founder and director of the Center for Green Psychiatry in West Lake Hills, Tex. “Simply put, I think what we are looking at is adjustment disorder. That is probably how the DSM would define it.”

Adjustment disorder is one of the most frequently diagnosed mental health conditions, although it is also relatively understudied. It is really a set of disorders that follow in the wake of a significant stressor, which can vary from serious illness or the death of a loved one to relocating or experiencing work problems. The resulting dysfunction and distress that the person experiences are considered out of proportion in duration or scale with what would normally be expected. Diagnosing an adjustment disorder is made difficult by the lack of a valid and reliable screening measure.

Recent literature suggests that coronaphobia may be likely to occur in those who feel vulnerable to disease, are predisposed to anxiety, or are intolerant of uncertainty. Preexisting mental health conditions can also be exacerbated by periods of quarantine, self-isolation, and lockdown, which can lead to panic attacks, chronophobia (fear of passing time), and suicidality.

Although imperfect comparisons, findings from earlier 21st century disease outbreaks, such as severe acute respiratory syndrome and the Ebola virus, signal that containment efforts themselves play a role in deteriorating mental health. A recent rapid review found that, in studies comparing persons who had previously undergone quarantines and those who had not, the former were significantly more likely to experience acute stress disorder, posttraumatic stress symptoms, and depression. Quarantine was found to result in long-term behavioral changes, such as avoiding crowds, among the general public and health care practitioners.

That tremendous psychological morbidity should accompany a global pandemic of this scale is not surprising, according to Amit Anand, MD, vice chair for research for the Center for Behavioral Health and director of the Mood and Emotional Disorders Across the Life Span program at the Cleveland Clinic.

“The technical definition of anxiety is an impending sense of doom, and I think all of us are living with that,” Dr. Anand said. “The basic question then becomes, what is normal and when does it become abnormal?”

He added that most classifications of psychiatric disorders are set during periods of relative stability, which the current moment is most certainly not.

“This is such an unusual situation, so I think it will depend on case-by-case basis, keeping the whole context in mind as whether the patient is thinking or behaving with an abnormal amount of anxiety,” Dr. Anand said.

Investigators are currently trying to give clinicians the tools to better make that determination. In the first scientific study of this clinical condition, Sherman Lee, MD, reported that five symptoms – dizziness, sleep disturbances, tonic immobility, appetite loss, and nausea/abdominal distress – were strong factors for distinguishing coronaphobia from otherwise normal concerns about COVID-19 that did not result in functional impairment. Dr. Lee and colleagues have since published further evidence that coronaphobia “is a unique predictor of psychological distress during the COVID-19 crisis.” They are working on validating a self-reported mental health screener for this condition.

Having the tools to identify patients struggling with coronaphobia may go some ways toward addressing another area of declining health. At the outset of the COVID-19 pandemic, there was a question as to whether doctors would be beset by a surge of the “worried well” – persons mistakenly believing themselves to be infected. Now months into the pandemic, the converse phenomenon – a fear of contracting COVID-19 that is driving patients away from practitioners – appears to be the more valid concern.

In early spring, the pandemic’s first surge was accompanied by reports of approximately 40% and 60% drops in visits to EDs and ambulatory centers, respectively. Stories of acute stroke patients avoiding treatment began to appear in the press. Major U.S. cities saw noteworthy declines in 911 calls, indicating a hesitancy to be taken to a hospital. That COVID-19 has been accompanied by mass unemployment and subsequent loss of insurance complicates the notion that fear alone is keeping people from treatment. In other countries, it has been explicitly linked. Investigators in Singapore noted that coronaphobia played a role in reducing willingness to attend in-person visits among adolescents with eating disorders. Similarly, case reports in Israel suggest that coronaphobia has contributed to delays in diagnoses of common pediatric diseases.

There is also a concern, colloquially termed “reentry anxiety,” that mental health problems caused by the pandemic, the accompanying lockdown, self-isolation, and quarantine practices will prove alarmingly durable. Even after this challenging moment in history draws to a close, many people may face substantial stress in returning to the normal activities of life – social, professional, familial – once taken for granted.

“We are in the beginning phase of that now,” said Dr. Anand. “Lots of people are decompensating, getting depressed, and needing treatment. I think the longer it goes on for, the more difficult it will be.”

In the United States, that day may seem far away. Nonetheless, it is important to begin laying the therapeutic groundwork now, according to Dr. Brown.

“I am recommending unconventional therapies like meet-up groups, online forums,” he said. “Everything has shifted online, and so there are a lot of support groups that patients can participate to learn coping skills and really hear what other people are going through.”

Before reaching that stage, Dr. Brown recommends that clinicians first simply discuss such anxieties with their patients in order to normalize them.

“Realize that everyone essentially is going through some degree of this right now. The coronavirus pandemic is literally impacting every person on the face of the planet. Sometimes just pointing that out to people can really help,” he said.

A version of this article originally appeared on Medscape.com.

During normal times, the U.K.-based charity No Panic offers itself as an easily accessible service to those with anxiety disorders and phobias. Visitors to the website who can receive immediate, remote support from trained volunteers. But this spring was anything but normal, as the reality of COVID-19’s worldwide spread became terrifyingly clear.

COVID-19 cases peaked in the United Kingdom in early April. Nationwide lockdown efforts contributed to a gradual but ultimately substantial decline in cases, yet, despite the favorable trend lines, No Panic has remained busier than ever.

Beyond the physical symptoms associated with COVID-19, the psychological outcomes are vast and, it seems, prolonged. Researchers have now formalized a definition of the long-term mental maladies associated with the pandemic, collectively deeming them “coronaphobia.”

The term is a catch-all phrase for the fear and the emotional and social strain experienced by the general public in response to COVID-19. Obsessive behaviors, distress, avoidance reaction, panic, anxiety, hoarding, paranoia, and depression are some of the responses associated with coronaphobia. On the surface, these appear to be normal, somewhat fitting reactions to this surreal and frightening moment in time. However, for those experiencing coronaphobia, they are distinctly maladaptive and harmful.

“We had a serious rise in the use of our services, notably the helpline and email enquiries,” explained Sarah Floyd, No Panic’s volunteer advisor and social media coordinator. “It has been up and down all along, but more of an up since lockdown is easing.”

The group’s experience offers yet more evidence that the anxieties and fears caused by this global pandemic don’t flatten alongside the curve but instead linger as chronic problems requiring ongoing care.

“Every week in my clinic, I’m seeing people who are experiencing more anxiety and hopelessness and having an emotional response that is perhaps out of proportion to what one would expect, which is directly related to what is going on in the world right now with coronavirus,” said Gregory Scott Brown, MD, founder and director of the Center for Green Psychiatry in West Lake Hills, Tex. “Simply put, I think what we are looking at is adjustment disorder. That is probably how the DSM would define it.”

Adjustment disorder is one of the most frequently diagnosed mental health conditions, although it is also relatively understudied. It is really a set of disorders that follow in the wake of a significant stressor, which can vary from serious illness or the death of a loved one to relocating or experiencing work problems. The resulting dysfunction and distress that the person experiences are considered out of proportion in duration or scale with what would normally be expected. Diagnosing an adjustment disorder is made difficult by the lack of a valid and reliable screening measure.

Recent literature suggests that coronaphobia may be likely to occur in those who feel vulnerable to disease, are predisposed to anxiety, or are intolerant of uncertainty. Preexisting mental health conditions can also be exacerbated by periods of quarantine, self-isolation, and lockdown, which can lead to panic attacks, chronophobia (fear of passing time), and suicidality.

Although imperfect comparisons, findings from earlier 21st century disease outbreaks, such as severe acute respiratory syndrome and the Ebola virus, signal that containment efforts themselves play a role in deteriorating mental health. A recent rapid review found that, in studies comparing persons who had previously undergone quarantines and those who had not, the former were significantly more likely to experience acute stress disorder, posttraumatic stress symptoms, and depression. Quarantine was found to result in long-term behavioral changes, such as avoiding crowds, among the general public and health care practitioners.

That tremendous psychological morbidity should accompany a global pandemic of this scale is not surprising, according to Amit Anand, MD, vice chair for research for the Center for Behavioral Health and director of the Mood and Emotional Disorders Across the Life Span program at the Cleveland Clinic.

“The technical definition of anxiety is an impending sense of doom, and I think all of us are living with that,” Dr. Anand said. “The basic question then becomes, what is normal and when does it become abnormal?”

He added that most classifications of psychiatric disorders are set during periods of relative stability, which the current moment is most certainly not.

“This is such an unusual situation, so I think it will depend on case-by-case basis, keeping the whole context in mind as whether the patient is thinking or behaving with an abnormal amount of anxiety,” Dr. Anand said.

Investigators are currently trying to give clinicians the tools to better make that determination. In the first scientific study of this clinical condition, Sherman Lee, MD, reported that five symptoms – dizziness, sleep disturbances, tonic immobility, appetite loss, and nausea/abdominal distress – were strong factors for distinguishing coronaphobia from otherwise normal concerns about COVID-19 that did not result in functional impairment. Dr. Lee and colleagues have since published further evidence that coronaphobia “is a unique predictor of psychological distress during the COVID-19 crisis.” They are working on validating a self-reported mental health screener for this condition.

Having the tools to identify patients struggling with coronaphobia may go some ways toward addressing another area of declining health. At the outset of the COVID-19 pandemic, there was a question as to whether doctors would be beset by a surge of the “worried well” – persons mistakenly believing themselves to be infected. Now months into the pandemic, the converse phenomenon – a fear of contracting COVID-19 that is driving patients away from practitioners – appears to be the more valid concern.

In early spring, the pandemic’s first surge was accompanied by reports of approximately 40% and 60% drops in visits to EDs and ambulatory centers, respectively. Stories of acute stroke patients avoiding treatment began to appear in the press. Major U.S. cities saw noteworthy declines in 911 calls, indicating a hesitancy to be taken to a hospital. That COVID-19 has been accompanied by mass unemployment and subsequent loss of insurance complicates the notion that fear alone is keeping people from treatment. In other countries, it has been explicitly linked. Investigators in Singapore noted that coronaphobia played a role in reducing willingness to attend in-person visits among adolescents with eating disorders. Similarly, case reports in Israel suggest that coronaphobia has contributed to delays in diagnoses of common pediatric diseases.

There is also a concern, colloquially termed “reentry anxiety,” that mental health problems caused by the pandemic, the accompanying lockdown, self-isolation, and quarantine practices will prove alarmingly durable. Even after this challenging moment in history draws to a close, many people may face substantial stress in returning to the normal activities of life – social, professional, familial – once taken for granted.

“We are in the beginning phase of that now,” said Dr. Anand. “Lots of people are decompensating, getting depressed, and needing treatment. I think the longer it goes on for, the more difficult it will be.”

In the United States, that day may seem far away. Nonetheless, it is important to begin laying the therapeutic groundwork now, according to Dr. Brown.

“I am recommending unconventional therapies like meet-up groups, online forums,” he said. “Everything has shifted online, and so there are a lot of support groups that patients can participate to learn coping skills and really hear what other people are going through.”

Before reaching that stage, Dr. Brown recommends that clinicians first simply discuss such anxieties with their patients in order to normalize them.

“Realize that everyone essentially is going through some degree of this right now. The coronavirus pandemic is literally impacting every person on the face of the planet. Sometimes just pointing that out to people can really help,” he said.

A version of this article originally appeared on Medscape.com.

During normal times, the U.K.-based charity No Panic offers itself as an easily accessible service to those with anxiety disorders and phobias. Visitors to the website who can receive immediate, remote support from trained volunteers. But this spring was anything but normal, as the reality of COVID-19’s worldwide spread became terrifyingly clear.

COVID-19 cases peaked in the United Kingdom in early April. Nationwide lockdown efforts contributed to a gradual but ultimately substantial decline in cases, yet, despite the favorable trend lines, No Panic has remained busier than ever.

Beyond the physical symptoms associated with COVID-19, the psychological outcomes are vast and, it seems, prolonged. Researchers have now formalized a definition of the long-term mental maladies associated with the pandemic, collectively deeming them “coronaphobia.”

The term is a catch-all phrase for the fear and the emotional and social strain experienced by the general public in response to COVID-19. Obsessive behaviors, distress, avoidance reaction, panic, anxiety, hoarding, paranoia, and depression are some of the responses associated with coronaphobia. On the surface, these appear to be normal, somewhat fitting reactions to this surreal and frightening moment in time. However, for those experiencing coronaphobia, they are distinctly maladaptive and harmful.

“We had a serious rise in the use of our services, notably the helpline and email enquiries,” explained Sarah Floyd, No Panic’s volunteer advisor and social media coordinator. “It has been up and down all along, but more of an up since lockdown is easing.”

The group’s experience offers yet more evidence that the anxieties and fears caused by this global pandemic don’t flatten alongside the curve but instead linger as chronic problems requiring ongoing care.

“Every week in my clinic, I’m seeing people who are experiencing more anxiety and hopelessness and having an emotional response that is perhaps out of proportion to what one would expect, which is directly related to what is going on in the world right now with coronavirus,” said Gregory Scott Brown, MD, founder and director of the Center for Green Psychiatry in West Lake Hills, Tex. “Simply put, I think what we are looking at is adjustment disorder. That is probably how the DSM would define it.”

Adjustment disorder is one of the most frequently diagnosed mental health conditions, although it is also relatively understudied. It is really a set of disorders that follow in the wake of a significant stressor, which can vary from serious illness or the death of a loved one to relocating or experiencing work problems. The resulting dysfunction and distress that the person experiences are considered out of proportion in duration or scale with what would normally be expected. Diagnosing an adjustment disorder is made difficult by the lack of a valid and reliable screening measure.

Recent literature suggests that coronaphobia may be likely to occur in those who feel vulnerable to disease, are predisposed to anxiety, or are intolerant of uncertainty. Preexisting mental health conditions can also be exacerbated by periods of quarantine, self-isolation, and lockdown, which can lead to panic attacks, chronophobia (fear of passing time), and suicidality.

Although imperfect comparisons, findings from earlier 21st century disease outbreaks, such as severe acute respiratory syndrome and the Ebola virus, signal that containment efforts themselves play a role in deteriorating mental health. A recent rapid review found that, in studies comparing persons who had previously undergone quarantines and those who had not, the former were significantly more likely to experience acute stress disorder, posttraumatic stress symptoms, and depression. Quarantine was found to result in long-term behavioral changes, such as avoiding crowds, among the general public and health care practitioners.

That tremendous psychological morbidity should accompany a global pandemic of this scale is not surprising, according to Amit Anand, MD, vice chair for research for the Center for Behavioral Health and director of the Mood and Emotional Disorders Across the Life Span program at the Cleveland Clinic.

“The technical definition of anxiety is an impending sense of doom, and I think all of us are living with that,” Dr. Anand said. “The basic question then becomes, what is normal and when does it become abnormal?”

He added that most classifications of psychiatric disorders are set during periods of relative stability, which the current moment is most certainly not.

“This is such an unusual situation, so I think it will depend on case-by-case basis, keeping the whole context in mind as whether the patient is thinking or behaving with an abnormal amount of anxiety,” Dr. Anand said.

Investigators are currently trying to give clinicians the tools to better make that determination. In the first scientific study of this clinical condition, Sherman Lee, MD, reported that five symptoms – dizziness, sleep disturbances, tonic immobility, appetite loss, and nausea/abdominal distress – were strong factors for distinguishing coronaphobia from otherwise normal concerns about COVID-19 that did not result in functional impairment. Dr. Lee and colleagues have since published further evidence that coronaphobia “is a unique predictor of psychological distress during the COVID-19 crisis.” They are working on validating a self-reported mental health screener for this condition.

Having the tools to identify patients struggling with coronaphobia may go some ways toward addressing another area of declining health. At the outset of the COVID-19 pandemic, there was a question as to whether doctors would be beset by a surge of the “worried well” – persons mistakenly believing themselves to be infected. Now months into the pandemic, the converse phenomenon – a fear of contracting COVID-19 that is driving patients away from practitioners – appears to be the more valid concern.

In early spring, the pandemic’s first surge was accompanied by reports of approximately 40% and 60% drops in visits to EDs and ambulatory centers, respectively. Stories of acute stroke patients avoiding treatment began to appear in the press. Major U.S. cities saw noteworthy declines in 911 calls, indicating a hesitancy to be taken to a hospital. That COVID-19 has been accompanied by mass unemployment and subsequent loss of insurance complicates the notion that fear alone is keeping people from treatment. In other countries, it has been explicitly linked. Investigators in Singapore noted that coronaphobia played a role in reducing willingness to attend in-person visits among adolescents with eating disorders. Similarly, case reports in Israel suggest that coronaphobia has contributed to delays in diagnoses of common pediatric diseases.

There is also a concern, colloquially termed “reentry anxiety,” that mental health problems caused by the pandemic, the accompanying lockdown, self-isolation, and quarantine practices will prove alarmingly durable. Even after this challenging moment in history draws to a close, many people may face substantial stress in returning to the normal activities of life – social, professional, familial – once taken for granted.

“We are in the beginning phase of that now,” said Dr. Anand. “Lots of people are decompensating, getting depressed, and needing treatment. I think the longer it goes on for, the more difficult it will be.”

In the United States, that day may seem far away. Nonetheless, it is important to begin laying the therapeutic groundwork now, according to Dr. Brown.

“I am recommending unconventional therapies like meet-up groups, online forums,” he said. “Everything has shifted online, and so there are a lot of support groups that patients can participate to learn coping skills and really hear what other people are going through.”

Before reaching that stage, Dr. Brown recommends that clinicians first simply discuss such anxieties with their patients in order to normalize them.

“Realize that everyone essentially is going through some degree of this right now. The coronavirus pandemic is literally impacting every person on the face of the planet. Sometimes just pointing that out to people can really help,” he said.

A version of this article originally appeared on Medscape.com.